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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> For Non-Transferable,( e able, Revocable,5uspendable) <br /> ;. �. PUMP&WELL <br /> ENVIRONMENTAL7HEALTH PERMIT <br /> ��� <br /> (COMPLETE IN TRIPLICATE) } WATER QUALITY+ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District" <br /> Exact Site Address City/Town <br /> Owner's Name 4 De9� Phone ��-s`��Z C> <br /> Address � '' <br /> '� City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address C Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Filel6th SJLHD? Yes No <br /> f <br /> TYPE OF WORK (CHECK): NEW WELLI❑ DEEPEN ❑ RECO ND DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER PUMP INSTALLATION PUMP REPA IR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line ._. Private Domestic Well Public D mestic Well I' <br /> INTENDED USE TYPE OF WELL <br /> I� - <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavdti6n <br /> 0;15-OMESTIC/PRIVATE ❑ DRILLED <br /> `'Dia. of WelhCasing � <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN GfYuge of-Casing^--- <br /> ❑ IRRIGATION ❑ GRAVEL PACK D'epthof-GFout%Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ,�s I Type of Grout <br /> ❑ DISPOSAL 4i ❑ �,�"+ <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL c ,. Surface Seal Installed By: <br /> PUMP INSTALLATION: ; Contractor _h <br /> Type of Pump n H.P. Wr <br /> PUMP REPLACEMENT: ❑ State Work Doig JC" <br /> IC <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ''4_ Approximate Depth <br /> A <br /> tDescribe Material and Procedure .4 1 , <br /> I hereby certify that I heave prepared this application and that the work' Iw II-be'done-in accordance with San Joaquin County <br /> _ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> .Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued ;-) shall n,6t.emplby any person in such manner as to become subject to'workman's compensation laws of California." <br /> Contractor's hiring or.sub-contracting signature certifies the following:"I certify that in"the performance of the work forwhich this <br /> permitisylssued, I shall employ persons subject to workman's compensation laws! <br /> of California." --? <br /> lar <br /> I wil for a Grout,ln ec'tion�prior to grouting and a final inspection - <br />,. Signed _ <br /> _Tltle:__�'[�lltic�4-�� Date: `O <br /> (Draw Plot Plan on Reverse <br /> FOR DEPARTMENT`USi ONLY" - "—; <br /> PHASE I <br /> I <br /> Application Accepted By Date y1 zZl-go { <br /> Additional Comments: If t <br /> Phase II Grout Inspection hays 11 Final Inspection <br /> Inspection ByDate Inspection By Date 2 <br /> Fee Is Due: 13ANNUALLY © PER UN171t] ❑ PER SkTE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> B{LLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED T <br /> AMOUNT <br /> FEEL[ <br />+ LESS - L <br /> PRORATION <br /> PLUS s <br /> .PENALTY <br /> OTHER - f <br /> . OTHER <br /> eived 6y : Date Receipt No. Permit No. Is uance Clate,- �VAailed.—De ed <br /> . T—RELL TURN-ACSS TO: . ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2011 STO KTON,CA 95201 <br />