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Applications Will Be Processed W66 P ubrnitied"! roperly Completed. Be Sure To Sign The Application. 'I.0 <br /> FOR OFFICE USE: ` = APPLICATION <br /> y -(For Non-Transferable, Revocable,g Suspendable) PUMP&WELL <br /> SAW JGAQUANrV�IRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE}`' g H DISTRiCT WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San.Joa uinGpunty Or mance No. 18 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact.Site Address City/Town /�I✓TC/�. <br /> Owner's Name L! �G ' Phone <br /> Address City I �mp .'3 . <br /> Contractor's Name .0 -Sca.✓ License#� Business Phone=e'i ig _2_ 1_7r-< <br /> Contractor's Address Emergency Phone Fi►`-�. ; <br /> aj <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_&ZA No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT IZ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IK DOMESTIC/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 /> ❑ DISPOSAL "❑.OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type'of Pump P. ; <br /> PUMP REPLACEMENT: O.State Work Done &f r VL C ,Z <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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 forwhich 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will or a Grout I s cti prior to grouting and a final inspection i <br /> Signed X Title: Dater <br /> (Draw Plot Plan on Reverse Side) # <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted` Date9-9.i2: <br /> Additional Comments:r - <br /> `-,,_-Phase II Grout Inspection Ph se til Final inspection �j- C <br /> Inspection By Date Inspection By. Date D -2-c-% l -I-.— f <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE E REMIT <br /> ' DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> I <br /> FEE y <br /> LESS + <br /> PRORATION it <br /> PLUS <br /> PENALTY' <br /> OTHER <br /> OTHER <br /> Received by Date Aeceipt 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 />