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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH;PERMIT <br /> 0 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY d <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with an Joaquin unt,Ordinance No. 1862 and the rules and regulations of the Saoagyl�n Local Health District. <br /> Exact Site Address City/Town -`- <br /> Owner's Name J' ^- l _ _ _ Phone 0 7 <br /> Address City. <br /> Contractor's Name License "3 73. Business Phone <br /> V <br /> Contractor's Address <br /> Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on Fie With SJLHD? Yes .u 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 /> 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 r <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 . ,�urfalnstalled By: <br /> PUMP INSTALLATION: Contractor T <br /> Type of Pump H.P. l �� <br /> PUMP REPLACEMENT: Mate Work Done x` 31 <br /> PUMP REPAIR: State Work Done a <br /> DESTRUCTION OF WELL: Well Diameter '�`' �' ' ' Approximate Depth r <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 Jdaguin-LocaI 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, d--sha!(-not ernploy.'.any'.pe'rson..in-such-manner_as_to become.subject,to workman;s-compensatio.n_laws_of California." \ <br /> Contractor's hiring or sub-contracting signature certifies the following:'9 certify that in the performance of the work forwhich this C <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w•I all for a Grout spection prior to grouting and a final insp�ectioon.- / <br /> Signed X `ritle: ' 'W _ _ Date: J + <br /> i (Draw Plot Plan on Reverse Side) <br /> !" FOR DEPARTMENT USE ONLY <br /> PHASE I, �°'�� / <br /> Application Accepted By_r �`_eo Dat 7�.y <br /> Additional:Comments: ` <br /> y Phase II Grout Inspection Phase II FinalInsp�e�cttiionn <br /> Inspection By - Date Inspection By at`iT e � <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT- ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ., <br /> ' REMIT <br /> BASE EXPLANATION BILLING _ REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT - <br /> FEE LikS <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER ' ?? <br /> Received by - Date Receipt No. Permit No. itsuancef DateMailed Delivered 'A <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1601 E.HAZELTON AVE.,P-O.Sam 2009 STOCKTON,CA 95201 ,f <br />