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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> FOR FILE USE: I APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ")MPLETE IN TRIPLICATE) WATER QUALITY <br /> `.Aication is hereby made tothe San Joaquin local Health Districtfora permit to construct and/orinstall the work herein described.This application is <br /> made in compliance wJ� a Joyg,qt1Iyj.ey�ty Qrrdinance 2 and the rules and regulations of the San J t District. <br /> Exact Site Address / �fJ S V i City/Town <br /> Owner's NameWWELLOEEPEN <br /> Phone 7, <br /> AddressCity— <br /> Contractor's <br /> vV <br /> Contractors Name e�� _ City ^ <br /> Contractor's Addresicense Han Business Phone I <br /> Emergency Phone <br /> Is Certificate Of Workman's CLHD7 Yes No <br /> TYPE OF WORK(CHECK): RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank-+—_100L— Sewer Lines Pit Privy <br /> Sewage Disposal i VFie�ltl CesspooVSeepage Pit Other <br /> Property Unr+y�Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ I USTRIAL 13 CABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ D Gauge of Casing <br /> ❑ IRRIGATION AVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Tf�� <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 <br /> PUMP REPAIR: ❑ State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure (n <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. fl <br /> Home ownerorlieensed agent's signature certifies the following:"I certify that in the performance of thework forwhieh thispermit (� <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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhieh this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I III call for Grout Inspection prlpr to grouting and a final inspection. <br /> i <br /> Signed X Title: Daw, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 y-q __ <br /> Application Accepted 8y �tJ�i Date -2 <br /> Additional Comments: <br /> h to II Grout In§pectio; Phalle III Final inspection <br /> Inspection By Data (o-A-4 Inspection By Date -q=&A <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE § REMIT <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> RadaWed M Date Aecelpt No. Permit NO. O ce MaYatl Delivered <br /> APPLICANT—RETURN ALL COPIES T6 ENVIRONMENTAL HEALTH PERMIT/Sis"CES 1601-F�.NAZELTON AVE,P.O.Roz ax% STOCKTON.CA,6401 <br />