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fik <br /> ppnca ionsWill Be Processed When Submitted Properly Completed. Be Sure To Sign Thehe Application. <br /> FOR OFFICE�Jt3E, �. a APPLICATION <br /> '`'(ForNon-Transferable,'Revo <br /> cable;Suspendable) <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . y <br /> t- Application is hereby made to the San�JoaquinLocal Health District fora permit toconstruct and/or install the work herein described.This applicationis <br /> made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the rules and regulations of the San Joaquin Loc I Health District. <br /> Exact Site Address <br /> I City/Town <br /> Owner's Name <br /> Address _ p Phone <br /> Contractor's Name JJ& <br /> City <br /> License# Business Phone�4_Y_;� 3_1,Q-a '� '7 9 �- <br /> Contractor's Address 3Y <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File.With SJLHD? . <br /> TYPE OF WORK (CHECK): NEW WELL 9 DEEPEN ❑ ' REYes= � No , <br /> I CONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ <br /> REPLACEMENT❑ WELL ABANDONMENT 11OTHER 13PUMP INSTALLATION PUMP REPAIR C] <br /> DISTANCE-TO'NEAREST: -Septic Tan `— - � •----Sewer Lines <br /> 1 I Pit Privy <br /> Sewage Disposal Field <br /> / CesspoVSeepa a <br /> it <br /> Property Lined or `Other. <br /> DomesticPrivate <br /> Well Public Domestic Well 1 <br /> INTENDED USE TYPE OF WELL t 1 <br /> ❑ INDUSTRIAL &I-CABLE TOOL �r <br /> 10 Dia. of Well Excavation�� <br /> DOMESTIC/PRIVATE El DRILLED Dia, of Well Casing , <br /> E DOMESTIC/PUBLIC DRIVEN❑ IRRIGATION Gauge of.Casing <br /> ❑ GRAVEL PACK Depth of Grout S01 <br /> DICATHODIC PROTECTION <br /> E3 ROTARY <br /> DISPOSAL s Type of Grout <br /> ❑ OTHER t Other Information <br /> 11 GEOPHYSICAL _ ) Surfs Seal'Installed By: <br /> PUMP INSTALLATION: Contractor <br /> # - ► h <br /> Type tof Pump � <br /> PUMP REPLACEMENT: 13State Work Done H.P. <br /> PUMP REPAIR: ❑ State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter +� <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I here y,certify that I have prepared this application and that the work will be done in accordance withzSan.Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. s <br /> Homeowner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit <br /> is issued,'i shall not employ i <br /> p Y an Y person in such marirer�as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifie's the'follow g"1 certify that in the performance of the work for which this <br /> permit is Issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call!or a Grout Inspection prior to grouting and a final lnspe�ct,ion. <br /> Signed X ' Date: / <br /> . (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> i <br /> Application Accepted By <br /> Additional Comments: j -"' Date <br /> Phase 11 GroutJl.nspection { Phase ill Final Inspection1. <br /> Inspection By �� �� pate `S Inspection By <br /> Z Date / �L 1 <br /> t' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ r <br /> `X r EACH <br /> __.❑ January 1 &Received By January 31 ❑ July.1 &Received By July 31 <br /> • �"" B SE EXPLANAZON— BILLING 7 REMITTANCE $ REMIT _ <br /> DATEGATE REMITTED AMOUNT DUE CHECKED <br /> FEE cm + AMOUNT <br /> LESS , f <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. <br /> • Iss ante Dae Mailed Dell <br /> ivered <br /> APPLICANT,RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E-HAZELTON AVE•,P.O.Box 2909. STOCKTON,CA 95204' <br />