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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE 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 fora permitto construct and/or install the work herein described.This application is <br /> made in compliance wilt San Joaquin County/ rdinance No.j8q2 and the rules and regulations of the San Joaquin cal Health District. <br /> Exact Site Address_,97% 1/r ty _ City/Town �S c "M <br /> Owner's Name n c� w ! Z Phone . R' Q` ?4Z- <br /> Address 919 - City c <br /> Contractor's Name License#�?,K &_ Business Phone . 0!�7—Zf/O <br /> Contractor's Address Emergency Phone <br /> Is <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- l(- No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑" DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ I t <br /> DISTANCE TO NEAREST: Septic Tank tO + Sewer Lines SCS + Pit Privy <br /> Sewage Disposal Field X0,0 l-f Cesspool/Seepage Pit Other <br /> r <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation f.x <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> © IRRIGATION Xr GRAVEL PACK Depthfof Grout Seal r <br /> E] CATHODIC PROTECTION 0 ROTARY Type of Grout 4f�dE.4r.Li r <br /> ❑ DISPOSAL ❑ OTHER Other Information l J <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r-/,z _ <br /> PUMP INSTALLATION: Contractor <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 /> a <br /> 1 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 forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a ro Ins c ' n prior to grouting and a final inspection. <br /> 1 <br /> Signed X Title: Date: e� <br /> (Draw Plot Plan"on Reverse Si ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI VL1 <br /> Z <br /> Application Accepted By - Date I <br /> Additional Comments- <br /> 0 I JGrout Inspection m ha a III Final Inspection �} �,� <br /> Inspection E Date /I _C�`9 0 Inspection By Date nC' Y{aL tic+ <br /> Fee}5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & e rved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER q <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95 <br />