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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICFSUSE: APPLICATION <br /> GO (For Non-Transferable, Revocable,Suspendable) ell PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconstructand/orinstall thewc hAeeiJISMAIN, his application is <br /> made in compliance with San Joaquin County Ordinance o. 1862 and th rules and regulations of the Sar!-Joag u"n'T aI�M.I, District, <br /> Exact Site Address '4..' �� City/Town <br /> Owner's Named O^ 3 Phone <br /> Address dy City <br /> Contractor's Name( License#113 Z ~Business Phone V10 p— _!!qe 46 <br /> r-- <br /> Contractor's Address Emergency Phone + <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes K No —� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION v 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 <br /> 151 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 By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done do -J <br /> PUMP REPAIR: ❑ State Work Done C7 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth D <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 /> 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, l 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 fallowing:"I certify that in the performance of the work for which this LJ <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection p to rou' and a final inspection. <br /> Signed a<.+� Date: INA F <br /> (Draw Plot Plan on lqere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I cu,DL� <br /> Application Accepted By ► � l! Date <br /> Additional Comments: <br /> e 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By �— Date / <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 /> of <br /> FEE �s " q S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. IsS ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20139 STOCKTON,CA 96201 <br />