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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,'Revocable, Suspendable) ,PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> 4.vT, <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct anS/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 Vi �- � � �" � City own <br /> Owner's Name �' L��� j \ gi U •C�u` Phone-,.,►-+'.. <br /> Address az:� � r �s,:-' . - -. i City w. <br /> Name fi <br /> Contractor's Nam ' - License 5 Z= Business Phone <br /> Contractor's Address 7Emergency Phone. « ' : � i�L,, " <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes it No <br /> TYPE OF WORK (CHECK): "NEW WELL❑ DEEPEN ❑ RECONDITION 11.--"'DESTRUCTION-13` " <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tankf r"' Sewer Lines rt 'r' Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Rit-.. 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 /> P�-QOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL ACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL <br /> ❑ OTHER Other Information y" <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 37Z <br /> Type of Pump M.P. <br /> PUMP REPLACEMENT: �' ,State Work Done_�.r <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure Q <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. ' <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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 4� <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this N' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for-a Grout Inspection prior to grouting and a final inspection. t <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout inspection Phas I Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑,PER UNIT ❑ PER SITE ❑-EACH •-January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - - BASE ^ EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE' �' - - - -- - - I S. 4 - <br /> 1 � <br /> E LESS. " T i <br /> PRORATION i <br /> PLUS k 5 . in <br /> PENALTY e _ <br /> OTHER <br /> OTHER <br /> -`,-Received by __.- ._ Date„ t .Receipt NO. - Permit No __ Issuance Date Mailed —Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />