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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR"cFICE use: APPLICATION <br /> - (Far Non-Transferable, Revocable, Suspendable) �I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is 07 <br /> made in compliance `w th San Joaquin Co my Ordinance No. 186 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address l � !a .r.[�J1/I �, City/Town / j ✓,� i � �� <br /> 8 Z3— <br /> Owner's Na a Phone <br /> Address City, <br /> Contractor's Name License 7z, 13usiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Work n n's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> II Sewage Disposal Field Cesspool/Seepage Pit Other <br />` Property Line Private Domestic Well Public Domestic Well <br /> i - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL , _ Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLEDa... Dia. of Well Casing <br /> 13DOMESTIC/PUBLIC C1DRIVEN Gauge.of Casing G J <br /> ❑ IRRIGATION Q -GRAVEL PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION 94 ROTARY Type of Grout <br /> ❑ DISPOSAL , {❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _ <br /> PUMP INSTALLATION: -N Contractor I, y <br /> Type of Pump' _— H.P, I" <br /> PUMP REPLACEMENT: ❑"State Work Done <br /> PUMP REPAIR: ❑ State Work Done -4­ <br /> DESTRUCTION <br /> _ <br /> IIG DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material a'Kd 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:"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 call <br /> for a Grou Inspection prior to grouting and a final inspection. <br /> Signed X _. C 11 P . Title: / /�} Date: <br /> # (Draw Plot'Plari on-Reverse Side) r <br /> 1 <br /> FOR DEPARTMENT USE ONLY 1= <br /> PHASE p� ) <br /> Application Accepted By- Date C Q <br /> Additional Comments: <br /> Phase 11 Grout Inspection Q Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee 11 Due: ❑ ANNUALLY ❑ PER'UNIT. ❑ PfR SITE ❑ EACH ❑ danuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITTANCE $ REMIT <br /> j BASE EXPLANATION AMOUNT DUE CHECKED <br /> f DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY XP <br /> "f <br /> OTHER <br /> OTHER ' <br /> l <br /> 7-7'1 9t2 ` <br /> Received by - Date-r }q -'Receipt 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 /> Ti f � <br />