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Applications Will Be Processed When SubAmiitttee dIProperly CATIQNpleted. Be SureToSign TneAppHcaLIUF1. <br /> FOR OFFICE USE: PUMP&WELL <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District a permit to construct and/or install the work herein described.This application is <br /> Application is hereby madeto the San Joaquin <br /> made in compliance with San Joaquin County Or finance fy0: 1862 d the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> a r . <br /> f� Phone <br /> Owner's Name Q �ity' ` <br /> Addresse Ph <br /> �f ZJ Business on �' <br /> ���/ v„ � License#�,� � <br /> Contractor's Nam <br /> Contractor's Address�aa will Emergency Phone <br /> K No — I <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL 13 []EEPEN ❑ RECONDITION❑ — DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 1:1 PUMP INSTALLATION 13 PUMP REPAIR $ <br /> REPLACEMENT❑ Pit Privy + <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> ,.-..Cess oo!/Seepage Pit Other t <br /> Sewage Disposal Field p <br /> Property.Line Private DomestidWell Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing j <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal j <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> C3 GEOPHYSICAL W Surface Seal Installed By: <br /> Contractor 4 <br /> f PUMP INSTALLATION: H p <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 21 state Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate�Dpth <br /> Describe Material and Procedure <br /> im <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> L ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 be to workman's.compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the tollowing:�l 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 ! #ill call for a Grout Ins e. _ fpr r rout pnd inal insp ct on. T <br /> Date: <br /> Signed <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date ' �— <br /> Application Accepted By <br /> l <br /> Additional Comments: s I i inspection <br /> Phase II Grout Inspection = ?� <br /> Inspection By <br /> Date Inspection By Date <br /> ❑ ❑ PER UNIT [I PER SITE ❑ EACH E3 January 1 &Received By January 31 ❑ ;uly 1 &ReceivedByJuly 31 <br /> Fee 1s Due: ANNUALLY <br /> i. BILLING .REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ' EXPLANATION DATE DATE REMITTED: AMOUNT <br /> FEE 4S� V <br /> LESS <br /> t .,y PRORATION <br /> PLUS <br /> i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. ate' Mailed :Delivered <br /> Permit No s anc D <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />