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Applications Will Be Processed When Submitted Properly Completed.BeSureToSignTneAppllcanon.�� <br /> FOR OFFICE USE: APPLICATION G -.1 <br /> (For Non-Tran§fera6le,Revocable;Suspendable) PUMP&WELL �. <br /> ENVIRONMENTAL <br /> HEALTH PtRMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY tY . 4� , . <br /> Application is hereby made to the San Joaquin Local Health District fo-r a pemi <br /> rtto construct and/or install,the work herein described.This application is <br /> made in.compliance.withrrS-±±an Joaquin CountOrdinanc a No. 1862 and the rules and regulationsof the San Joaquin Local Health District. <br /> Exact Site Address �7 7��_ _cam ��} Y City/Town <br /> Phone' �'� C <br /> Owner's Name - <br /> Address r,. .. a City <br /> Contractor's Name "' License tl~7? Business Phone-,.,. r j <br /> s f* ; s " n :" at»,rr Ir-.r�.- <br /> Contractor's Address 'Emergency Phone S } <br /> Is Certificate of Workman's compensation Insurance on File With SJLHD? Yes �' No J d <br /> TYPE OF WORK (CHECK): NEW WELL❑'- DEEPEN ❑7 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION UMP REPAIR❑ 1 <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Cesspool Pit Other <br /> - Sewage Disposal Cess Field � - -{ P -�-, <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND TRIAL ❑ CABLE TOOL Dia. of.Well Excavation <br /> OME5TIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC I- <br /> -1 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL f i Surface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: 13State Work Done <br /> I PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: x Well Diameter Approximate Depth <br /> Describe Material and Procedure ` <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 for which this permit <br /> is issued, l 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 I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> a Grout IN cIII prior to grouting and a final inspection. <br /> Signed Title: _ t7!T-& Date: [+� <br /> (Draw Plot Plan on Reverse Side) <br /> # FOR DEPARTMENT USE ONLY <br /> PHASE I Date- <br /> Application Accepted By OF <br /> k Additional Comments: <br /> Phase II Grout Inspection has 1 aI Inspection / Gr <br /> , • Date <br /> ,inspection By. Date - Inspection By <br /> I <br /> -= Fee IS Due: ❑ ANNUALLY ❑ PER UNIT .' ❑ PER SITE ❑ EACH. "❑ January 1 &Received By January 31 ❑ July 1 &Received By 31 <br /> - BILLING REMITTANCE ,. $ AMOUNT DUE CHECKED. <br /> 'BASE EXPLANATION <br /> �yy DATE DATE REMITTED AMOUNT <br /> I FEE' �V•t �- . <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER LLI <br /> Received by Dater 1, + -- Receipt.No. _Permit.No.- i!- L- Issifanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.SON 2009 STOCKTON,CA 95201 <br />