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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign he Appli alien. ° <br /> 715JR,OFF.lCE USE: k APPLICATION �� Q. �� 1 a <br /> (For Non-Transferable, Revocable,Suspendable) <br /> .4 - � PUMP&WELL, ,f�. <br /> ENVIRONMENTAL HEALTH PERMIT II,� (, P <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . . " I, - ► <br /> Application is hereby made to the San Joaquin Local Healti-i District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq County Ord' c6.No. 1862 and the rules an r ulations of the San Jo in oral Health District. <br /> Exact Site Address + City/Town <br /> I==--- ca-- — <br /> Owner's Name Phone l qr <br /> Address V <br /> - City—_edz;_ C* <br /> Contractor's Name. _ �!�!� Licensed Business Phone <br /> Contractor's Address 5 e!r�Emergency Phone l <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 9-- 'PUMP REPAIR❑ <br /> REPLACEMENT❑ # t <br /> DISTANCE TO NEAREST: Septic Tank /06 � Sewer Lines Pit Privy <br /> i Sewage Disposal Field Cesspool/Seepage Pit Other <br /> F Property Line Private Domestic Well Public Domestic Well - <br /> f INTENDED USE TYPE OF WELL f �� <br /> k <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _ --- <br /> ir <br /> ©"'DQMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing zy <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION E - i�OTARY Type of Grout m, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL rtace Seal lWalle. d y: 4- _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump " H.P. <br /> PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 6e I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> . J ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> a oo Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> 1 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 Grout Inspection prior to gro g and a final inspection. p <br /> l Signed X "� '�/ ��y Title: Date: <br /> (Draw Piot Plan on Reverse Side) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date �- <br /> Additional Comments: ��� - - <br /> Phase out In ection Ph Final nspection / <br /> Inspection By ate � U Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> 'BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY ale <br /> ' OTHER <br /> OTHER <br /> Pic <br /> Received by Date Receipt No. Permit No. ,- Iss ante-D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/sERVLCES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />