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Applications Will Be Processed When Submitted ProperlyCompleted tie sure iosign Ine.appilVauun. <br /> FOR OFFICE USE: APPLICATION <br /> ` (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 6 Districtforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Application is hereby made to the San Joaquin Local Health <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 -S 7 -� !� <br /> �.2 City/Town �� J <br /> Owner's Name ` Phone <br /> Address a City <br /> Contractor's Names License Business Phone J <br /> Contractor's Address .2- a 5t;2 'Emergency Phone 4516- 1<-1 !9 l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes 4_� No <br /> TYPE OF WORK (CHECK): NEW WELL 8r DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2�P MP REPAIR❑ Vn <br /> REPLACEMENT❑ �l <br /> DISTANCE TO NEAREST: Septic Tank + Sewer LAS "" Pit Privy —d.&99=e_ \ <br /> Sewage Disposal Field f Q ' Cesspool/Seepage Pit I f O '4- Other <br /> s <br /> k Property Line Private'Domestic Well, Public Domestic Well <br /> INTENDED USE - TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> ❑ DRILLED Dia. of Well Casing e,�"OOMESTIC/PRIVATE G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Q <br /> ❑ CATHODIC PROTECTION E ITOTARY Type of Grout <br /> ❑ DISPOSAL ❑ OtHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installe By: 'G <br /> I PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter- r� p' Approximate Depth <br /> Describe Material and Procedure- 1 <br /> I'hereby certify that 1 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 /> 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 become subject to workman's compensation laws of California." <br /> x Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> F permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will ca for a Grout Inspection prior to grouting and a final inspection. <br /> /? MSigned X f Title: Date: <br /> (D <br /> ` aw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 - 21 <br /> Application Accepted By `� Date <br /> Additional Comments <br /> Phase 11`Grdut Inspection Phase III Fina spection <br /> Inspection By �� Date '� - Inspection By �January3l <br /> Date <br /> -Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &Received BJuly 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> FEE ��• .— d (� ��� <br /> LESS <br /> 1 PRORATION _ - <br /> PLUS <br /> PENALTY - -- <br /> OTHER E <br /> A <br /> OTHER - ._. _- ' a•` { - <br /> i." Received by Date Me Receipt No Permit No.` Issuance Date Mailed - w De ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />