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�. <br /> .,... .-rr <br /> Applications Will Be Processed When SufAPPLIL.AITION � <br /> sFOA OFFICE USE: ! <br /> (Far Non-Transferable, Revocable, Suspendable) PUMP&WELL t <br /> ENVIRONMENTAL HEALTH PERMIT r f y <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health Districtforapermittoconstructand/orinstallthework herein described.This applica <br /> Application is hereby made to the San Joaquin Is <br /> Oounty Ordinance No.1862 and the rules and regulati on <br /> Citof the San Joaquin Local Health District. <br /> made in compliance with San Joaquin <br /> Exact Site Address <br /> Phone �3 <br /> Owner's Name City <br /> Address <br /> License Business Phone <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File ith SRECO Yes r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER 11PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT[] Sewer Sewer Lines Pit Privy � <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other j <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ I STRIAL ❑ CABLE TOOL Dia. of Well Excavation .1 <br /> D DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE <br /> ElDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> of Grout Seal <br /> Depth <br /> 11 IRRIGATION <br /> 13 GRAVEL PACK \ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Installed B <br /> 11 GEOPHYSICAL Surface <br /> Seal Y <br /> I Contractor <br /> ' PUMP INSTALLATION: H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Weh,Diameter <br /> Describe Material and Procedure ~� <br /> { <br /> l hereby certify that l have prepared this application and that the work will be done in accordance with San.Joaquin County <br /> ordinances, state laws, and rules.iand regulations of the San Joaquin Local Health District. <br /> Home owner or licensed�agent's signature certifies the following:1 certify that in th workmanas cormpensarilf the Qonrk f�aws of Gal for which this m alt <br /> is issued�l shall not employ any person in such manner as to become subject to <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I wit r a Grout Inspection prior to grouting and a final inspection. <br /> tDate:,,:? <br /> Title: <br /> Signe <br /> (Draw Plot Plan on Reverse Side) <br /> l FOR DEPARTMENT USE ONLY <br /> PHASE I } Date 3 � <br /> j Application Accepted By F <br /> Additional Comments: ! <br /> Phase 11 Grout Inspectio Phase 111 Final Inspection <br /> IkI I Date <br /> Date Inspection By <br /> inspection By <br /> /£ ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY t ❑ PER UNIT 1 REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> gggE EXPLANATION DATE REMITTED __AMOUNT <br /> DATE - <br /> Ll 5 <br /> FEE � <br /> LESS I <br /> F PRORATION (y <br /> PLUS S d r <br /> PENALTY <br /> OTHER g <br /> OTHER ! <br /> I, Receipt No. Permit No. - <br /> I sua at f Mailed De' ad <br /> Received by Date 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />