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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureTosign 1neRkppucatfun. <br /> APPLICATION <br /> F�OR_OF ICE USE: f _. <br /> ' (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> r <br /> (COMPLETE IN TRIPLICATE) (•, WATER QUALITY <br /> Application is hereby madetothe San Joaquin.Local Health Districtfora permitto construct and/or nstall the work.herein described.This applidation is <br /> made in Tmplrance ith San Joa uin=.County,Ordinance�No. 1862tand th rules and regglations of the SafiJoaquin Local Health District <br /> i a rU <br /> Exact Sit Address5� , City/Town <br /> Owne�� Name a = Phone <br /> Address ao`- City <br /> Contractor's Name i License#_ 9D,J� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ _� No } <br /> i' TYPE OF WORK (CHECK): NEW WELL q1--' DEEPEN ElRECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR El <br /> I. <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> aSewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 13I USTRIAL ❑ CABLE TOOL Dia. of Well Excavation �Q Ila <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOME571C/PUBLIC ❑�, DRIVEN Gauge of Casing � <br /> ❑ IRRIGATION LSC' VEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ` PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r - <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. x _ � <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance:of the work for which this permit <br /> is issued, I shall not employ 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 performarsc of the w.ork forwhrch this° <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." '' <br /> r I wi 1 call fora Grout In tion prior to grout' g and a final i speetion. <br /> Signed X Title- <br /> (Draw Io Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r Y � // <br /> 7,�M�L�. <br /> Application Accepted By <br /> ;Date <br /> Additional Comments: - . <br /> t h s II Grout Inspection P7_ .. inal on <br /> Inspection By j Date Inspection By � Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January i &Received By January 31 ❑ July 1 &Received By July 31R MIT ' <br /> i ! BILLING REMITTANCE $ AMOUNTDUE - <br /> ' EXPLANATION CHECKED <br /> BASE <br /> t DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r, PLUS - <br /> PENALTY -- <br /> OTHER <br /> OTHER <br /> �� -�'z Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received try- <br /> LICANT=RETUAN ALL COPIE$TO:_ L HEALTH PERMIT/SERVICES 1501 E.HAZEL TON-AYE.,P.O.Boy 2009 STOCKTON,CA 95201- <br /> . <br /> rt ' <br /> N <br /> N <br /> I.. <br /> 0 <br /> V <br />