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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign ineApplication. <br /> FOR oFFiE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY / <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address City/Town <br /> S <br /> 10. <br /> Owner's Name VIC. Phone - <br /> Address City I <br /> Contractor's Name t icense# = Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance n 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 TankSewer Lines37,la_/4_:_— Pit Privy k'°-`*< <br /> Sewage Disposal Field B Cesspool/Seepage Pit Other <br /> Property Line If Private Domestic Well A"4'0-4 Public Domestic Well r✓ !n— <br /> INTENDED USE TYPE OF WELL . <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> P'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 Ye, H.P. <br /> PUMP REPLACEMENT: 9-State Work Done_4 �A-t7�� �� �r 0 <br /> PUMP REPAIR: El State Work Done U _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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, 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 /> 1/will III a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> L; Title: Date: <br /> (Draw Plot Plan on:Revers!, Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `Zf <br /> Application Accepted By J Date <br /> Additional Comments: <br /> Phase 11 Grout inspection III FJ ° G <br /> Inspection By <br /> Date Inspecti ti ee �� t6 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE El EA EACH ❑ a Received By January 31 uary 1 & ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k _ :3 <br /> Received by Date Receipt No. Permit No.,. Is ante Date Mailed Delivered <br /> 1&01 E.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ <br />