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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF_ICE USE: APPLICATION <br /> = (For Non-Transferable, Revocable, Suspendable) <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 permit to construct and/or install the work herein described.Thisapplication'is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reWl tions <br /> f the San Joaquin District. <br /> Exact Site Address o�90s �• — bti �a°: /_� City/Town .D SJR <br /> Owner's Name Phone �S <br /> Address City025 <br /> —1 <br /> Contractor's Name License # c2&F23 Business Phone <br /> Contractor's Address Emergency Phone j <br /> Is Certificate of Workman's Compensation Insura a 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❑ i <br /> DISTANCE TO NEAREST: Septic Tank q5 + Sewer Lines Pit Privy <br /> Sewage Disposal Field �5't Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑- INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ua'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing {� / <br /> ❑ DOMESTIC/PUBLIC ❑ DPIVEN Gauge of Casing <br /> 13IRRIGATION [ 'GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION QL- OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> w. u <br /> I will call for a Grout Inspec 'on prior to grouting and a final inspection. <br /> Signed X � Title: Pate: <br /> q <br /> (D& w Plot Plan on Reverse Side) <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I -- <br /> Application Accepted By �� Date . <br /> Additional Comments: <br /> Pbase 11 Grout, nspection FhV6 III i=i t inspection# <br /> Inspection By ate Z- & Inspection Bydo- 6L- <br /> ate fy <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July al <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE fp � OL�3 <br />_ LESS <br /> PRORATION <br /> 4 PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k <br /> t Received by ate Receipt No. Permit No, Issuance Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2009 STOCKTON,CA 95261 <br />