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Applications! III Be Processed When Submitted ProperlyCompleted. BeSureTo sign TneApplication. J <br /> FOR OFFICE USE: APPLICATION r f <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 21 <br /> ` WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install theworkherein described.This applicatign-nis k <br /> made in compliance with San Joaquin Cod'Ordi ante No.186�andjljhe rules and regulations of the Saoar�,ll in L H alth District. <br /> Exact Site Addre r� _�_ City/Town 1.� 5W <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name. IG License 43yO�Y - Business Phone- <br /> Contractor's Address mergency Phone N <br /> is Certificate of Workman's Compensation Insurance on 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❑ /A <br /> REPLACEMENT❑ !! ` l � i <br /> DISTANCE TO NEAREST_ 'Septic Tank e�-.-- Sewer LinesPit Privy" <br /> ir <br /> ' SewF,I. Disposal Fiend Cesspool/Seepage Pit �l�Q Other. i <br /> Property Lint.- - Private Domestic Well Public Domestic Well I <br /> f <br /> INTENDED USE I -TYPE OF WELL y � <br /> ❑ INDUSTRIAL I-PCABLE TOOL Dia. of Well Excavation t <br /> ADOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> i] CATHODIC PROTECTION ❑ ROTARY <—,Type`of Grout — <br /> ❑ DISPOSAL ❑ OTHER """" Other lnfbrmation ---- <br /> ❑ GEOPHYSICAL Surface Seal Installed By. <br /> t I <br /> PUMP INSTALLATION: Contractor <br /> ,+ Type of Pump A 2 H.P. t. <br /> PUMP REPLACEMENT: Y ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: I 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 lawsland rules and regulations of the San Joaquin Local Health District. C" <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> ris issued;I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> al <br /> Contractor's hiring or sIi ub-contracting signature certifies the following:"I certify that in the performance of the work for which this , <br /> permit is issued, I shah employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout uj spect'on prior to-grouting and a final inspection. t a <br /> Signed X <br /> Title: Date: <br /> 7Z SC) <br /> I1� (Draw Plot Plan.on Reverse Side) = , t <br /> FO DEP ART U ONLY _ '� y <br /> i PHASE I _J <br /> t <br /> f Application Accepted By r ! Date �� t <br /> Additional Comments: ,� _ _ _ <br /> Pha4e l Grout Inspection t Phas t I Final Inspection[y o <br /> Inspection By 1 ate 7;AL `' Inspection By ate `— —6 b <br /> � Fee IS Due: ❑ ANNUALLY PER UNIT '❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 <br /> }` 1 11 REMIT _ <br /> .1 BILLING _ REMITTANCE _ $ ...AMOUNT DUE: CHECKED <br /> I ...r.. �..�—^-RASED+- rEXPLANATI,ONDATE -- pgTE "REMITTEO"` - t� AMOUNT <br /> FEE <br /> LESS <br /> ' PRORATION Ip! <br /> PLUS <br /> PENALTY <br /> OTHER 3 <br /> k OTHER SIN, <br /> lDate Receipt e o a lot <br /> No.Received by NPermit No. Issuance Date Mailed Delivered <br /> a <br /> {, ii <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br /> q. �R <br />