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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION1,0000(For Non-Transferable, Revocable, Suspendable) ��� �J �- f <br /> ENVIRONMENTAL HEALTH PERMIT PUMA&WELL Q" <br /> �dG 17� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r 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 with San Joaquin Coun"ty�Ordi ance No. 1862 d the rules and regulations of the San Joaqui Local Health District- y <br /> Exact Site Address . 5P /v �o ;�1,� w City/Town <br /> Owner's Name <br /> Phone .3f <br /> Address City <br /> Contractor's Name � � <br /> License# Business Phone,_ <br /> Contractor's Address Emergency Phone 4 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_-K— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ a <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP WSTALLATIONX 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 WellPublic Domestic Well 7 <br /> INTENDED USE TYPE OF WELL 14' <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 5 ❑ ROTARY Type of Grout J <br /> ❑ DISPOSAL I, ❑ OTHER Other.Information <br /> ❑ GEOPHYSICAL < Surface Sealtailed By: J <br /> PUMP INSTALLATION: Contractor <br /> - Type of Pump � <br /> H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 00 <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 /> Home owner 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 /> I will call forta Gro Ins e�tion 4rio to grouting and a final inspection., <br /> Signed X Title: 044mrllDate: <br /> (Draw Plot Plan on Reverse Side) <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r <br /> Application Accepted By r <br /> Date <br /> Additional Comments: <br /> f <br /> Phase Il Grout Inspection Ph se III Final Ins ction <br /> Inspection By—*#-- Date Inspection By ate <br /> Fee Is Du•e: C1ANNUALLY ElPER UNIT 1:1PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July y 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT e� <br /> DATE DATE REMITTED AMOUNT DUE CHECKED J <br /> FEE AMOUNT <br /> ��s Sys <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> 1 <br /> OTHER <br /> /''low° 2 13 �-0 3 `S <br /> Received by Date Receipt No. Permit No. Issuance Date Maifed <br /> Delivered 3 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,aA 952♦) - i <br />