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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.';— <br /> h a <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL ` <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) l.Obc9yST�c-L'�V7WATER QUALITY <br /> Application is hereby madetothe'SanJoaquinLocalHea�lthDistrictforapermit toconstruct and/or install thework hereindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rules and regulations of the San Jo <br /> uin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name 4:�/7 Yr d . i o.v Phone <br /> IF <br /> Address wr — City A01:4., <br /> Contractor's Name License# Business Pho e <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 't <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> 4 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ? <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ 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 Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. k <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . ,r <br /> Describe Material and Procedure <br /> 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, 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 c Info Grout in do i t gr uting and a final in ti <br /> !rte/ f <br /> Sigried X Title: Date: � 'f <br /> (Draw Plot Plan on Reverse Side) <br /> ,. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted RO Date <br /> Additional Comments: <br /> rout Inspection final Inspection <br /> Ins ection B Date S��� <br /> P �` Inspectionreceived <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & By January 31 ❑ July 1 R Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> i <br /> LESS 71 <br /> \PRORATION � <br /> PLUS a <br /> PENALTY - <br /> r <br /> OTHER <br /> OTHER <br /> -Received by I Dat Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ., 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 "^�' <br />