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wpplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin 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 �r7h4*iL—Z Phone <br /> Address 1z erw � � City <br /> Contractor's Name <br /> License#� 7/ Business Phone <br /> Contractor's Address got l Emergency Phone '9-3L5-L_ 0�} <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION J PUMP REPAIR <br /> REPLACEMENT❑ I <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 Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARYType of Grout <br /> E] DISPOSAL ❑ OTHER �sOtFler Information <br /> El GEOPHYSICAL <br /> Snrface'Seal Installed By:--- --- — -�ti <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 /> i f Describe Material and Procedure <br /> t' <br /> I hereby certify that I Nave 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. <br /> Homeowner or licensed agents signature certifies the following:"I defytify that in the performance of the+uvork for which this permit <br /> is issued, I shall not employ any person in such manner as to becomesubject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanc I of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation la'w—"f California." <br /> I a Groutrl.nspection prior�S',ilroyting and a final inspectionl{ <br /> Signe ``�`� 4 Title: r Date:qi'17 _7! <br /> (Draw Plot Plan on Reverse35ide) <br /> r. i * Y4 i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date� <br /> Additional Comments: <br /> Phase II Grout Inspection P ase III Final Inspectio4FRId <br /> Inspection By Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 311 <br /> Y Y Y ❑ Ju1y 1By July 31 <br /> BILLING REMITTANCE s { MIT <br /> BASE EXPLANATION DATE DATE REMITTED + .,AMOUNT DUEHECKE <br /> AMONT <br /> [� <br /> FEEfNz ♦ f .,�`- T Q <br /> LESS <br /> PRORATION .. ,_ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t R <br /> :779_-111.0 tC>/tAj 7q <br /> Received by Date Receipt Na- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />