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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> �a # (For Non-Transferable,Revocable;Suspendable) PUMP&WELCa�pp7lic�a�tion,is ENVIRONMENTAL HEALTH PERMIT A/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Application is hereby made to the San Joaquin Local Health District for a permit toconstruct'and/or install the work hereindescribed <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joa u ocal Health District. <br /> Exact Site Address /L � � r �r�t do/ City/Town + <br /> Owner's'Name to e--e- . raar .0 Phone <br /> Address //�� . City <br /> — <br /> Contractor's Name License* Business Phone <br /> Contractor's Address Emergency Phone• <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? YES No <br /> TYPE OF WORK {CHECK): NEW WELL❑ DEEPEN ❑'1- RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRJI <br /> REPLACEMENT❑ <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 t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 6 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump c _a J, 'H•P• + <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> PUMP REPAIR: State Work Done , dr <br /> z <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> S <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 /> Home owner or licensed agent's signature certifies the following:1 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 for which this 1 <br /> permit is issued, I shall employ persons subject to Workman's compensation laws of California." [[ <br /> I will call for a Grout Inspecti ri torout a I nd a inal inspection. <br /> Signed X tle: ��� ,Date: 9z <br /> (Draw Plot Ian on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE j � . _ <br /> Application Accepted By -. -fir '�C..-- bate <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> tloci <br /> - Inspection By. _ . Date F Inspection By )Wt C041.A--� Date <br /> e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE i ❑ EACH ❑ January 1 &'Received By January 31 ❑ July 1 &Received By July 34 <br /> REMIT ' <br /> BILLING REMITTANCE $ <br /> - BASE - EXPLANATION- - - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �' S <br /> LESS _. <br /> PRORATION - <br /> PLUS C <br /> : PENALTY .. <br /> OTHER - v <br /> t <br /> OTHER -- -f.- - <br /> Received by Date Receipt No Permit No. _ Is uanc 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 />