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k ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> FOR OFQICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br />' PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)Ji j'QS'�cf 5'-C; ,�E uE� IATER 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 w' h n aq " County Ord 1862 and ule and regulakWo pf the San Joaquin Local Health District. <br /> Exact Site Address <br /> �-�/ U _F�' City/Town i <br /> Owner's Name - / —r Phone <br /> Address ` <br /> City v <br /> Contractor's Nam ((c'-nse#3 Cp,D Business Phone <br /> Contractor's Address ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t— No <br /> TYPE OF WORK (CHECK): NEW WELL L?'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�-- PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank fQ d Syawer Lines --"� Pit Privy _ <br /> Sewage Disposal FigId a d Cesspool/Seepage Pit Other ----- <br /> Property Line Private Domestic Well —"—'Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> , <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL Dia, of Well Excavation <br /> ,,�..,, <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �D Q <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information G, <br /> ❑ GEOPHYSICAL Surface/S,% Installed By: _ .l✓o �� /it,� "� <br /> PUMP INSTALLATION: Contractor U,...� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done F <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 4 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 7 I <br /> r F <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit '1 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." `r+ <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ p ns subject to workman's compensation laws of California." <br /> I I call for a Grou o rior t grouting and a final inspection. ' <br /> t i <br /> Signed X Title: Date: <br /> i. <br /> (Draw Plot Plan on Reverse Side) <br /> s..� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date �¢ <br /> Additional Comments: <br /> Phase II Grout Inspection as I Final Inspectio z.r <br /> Inspection By Date Inspection lay Date <br /> k <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Rece' ed By January 31 ❑ July 1 &Received By July 31 h <br /> BILLING REMITTANCE $ REMIT 1 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> Received by Datd Receipt No. Permit No. .1 ss ante to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />