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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF E USE: APPLICAT40N _ <br /> (For Non-Transferable, Revocaife,-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 District fora permit to construct and/or install the work herein described.-This application is <br /> made in compliance with a oaaui o my Ordialance No. 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address _ _ �_ .� City/Town <br /> Owner's Name <br /> (7U—X�- _�! 'U _ Phone <br /> Address C i t N <br /> Contractor's Name , ,( QJ License# Bus' ess Phone` �- i <br /> Contractor's Address 2L( f] A] �" i 11 Emergency Phone &" I ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL.❑ DEEPEN ❑ RECONDITION❑ STRUCTI N❑ <br /> WELL CHLORIN AT ❑ WELL ABANDONMENT ❑ OTHER El PUMP iNSTALLATIONV PUMP REPAIR El <br /> REPLACEMENTi <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> err <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_ M <br /> Property Line Priv-af,.Domestic Well Public Domestic Well <br /> INTENDED USETYPE pF WELL , <br /> ❑ INDUSTRIAL. ❑ CABLE <br /> OOL - Dia. of Well Excavation <br /> } <br /> ❑ DOMESTIC/PRIVATE ❑ DRILL7.� Dia. of Well Casing f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN_ '' Gauge of Casing - <br /> ❑ IRRIGATION ❑ GRAVEL PACK,t Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY - � Type of Grout <br /> ❑ DISPOSAL OTHER _ —Other Information +. l <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> ._. <br /> -A <br /> PUMP INSTALLATION: Contractor_ _ <br /> Type of Pump - �' _ <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done" '" _. <br /> PUMP REPAIR: ❑ State Work Done ' At i <br /> DESTRUCTION OF WELL: Well Diameter ' Apprcx>,oate Depth, '" - <br /> Describe•:Material and'Procedure <br /> I hereby certify that I have prepared this application and-tliat the work will be doneinaccordance with San Joaquin County s <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 performanceof 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 orsub-contracting signature certifies t following:"I certify that;in fhe perfbrmanc�of the work for which this <br /> permit is issued, I shall employ persons su to WO an's pensation laws of California." <br /> will call f a Grout Ins tion• rio routin d a fi speclion. <br /> Signed X 1 r e: '° ___ {s4" Date:- <br /> (Draw Piot Plan on,R,64se Side) <br /> -.- FOR"DEPARTMENT USE ONLS' <br /> 4ASE I <br /> Application Accepted By .r Date <br /> Additional Comments: <br /> .. v <br /> Phase 11 gout Inspection Pha a ill Final'Inspection <br /> Inspection By Date . " A Inspection By Dat <br /> 7 Ile <br /> Fee Is Due: ❑ ANNUALLY ❑-PER UNIT -, +❑ PER"SITE-., .'❑ EACH El January 1 &Received By January 3V "[] JWy 1 &Received By July 31 1 <br /> . . .._ki -3 REMIT _ <br /> BILLING REMITTANCE $ '� 1 <br /> BASE .:'EXPLANATibN AMOUNT DUE CHECKED <br /> - - -,• DATE. DATE 'REMITTED AMOUNT <br /> FEE / • c �; * ,. 4 <br /> LESS <br /> PRORATION <br /> _ PLUS -• T --. .- - 1W.' ;' ". -.`— __.. � a <br /> PENALTY e ' <br /> OTHER <br /> OTHER z•_ <br /> � - ��. 4^ r• <br /> Received by Date` 'Receipt No. Permit No. Issuance Date ; Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO�ENVtRO_NMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTQN AVE.,P.O.Box 2009' STOCKTON,CA 95201 �� <br />