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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) <br /> _ !'UMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Wal Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Spipigqquin Co rdinanc 2-and the rul s a regulations of the San Joac na.ocal Health District. <br /> Exact Site Address a S City/TownI <br /> a,.A <br /> Owner's Name Phone <br /> Address A City F <br /> Contractor's Name License# Business Phone <br /> i <br /> Contractor's Address Emergency Phone .+ <br /> Is Certificate of Workman's-Compensation Insurance on File With SJLHD? Yes No ob <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIPk <br />'i REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br />` INTENDED USE TYPE OF WELL <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 /> f ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> ii PUMP INSTALLATION: Contractor <br />'I Type of Pump H.P. <br /> i- PUMP REPLACEMENT: 11 State Work Done ' <br /> I PUMP REPAIR: State Work Done jff-A4*_AAL4-Cn0 c) <br /> DESTRUCTION OF WELL: Well Diameter V FrApproximate Depth <br /> I Describe Material and Procedure <br /> i <br /> i 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 for a Grout spection prior to grouting and a final inspe ion. <br /> moi+„sa r <br /> Signed`X Title, � _.� Date: <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> F PHASE I / �� /,(// J'/ } <br /> Application Accepted By Datel� <br /> d <br /> Additional Comments: <br /> Phase II Grout Inspection se III Final pection <br /> Inspection By Date Inspection B ` ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> L4 <br /> AMOUNT <br /> � <br /> FEES CO `ISO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY {{ <br /> L 1 <br /> OTHER <br /> i <br /> OTHER <br /> f Received by Date Receipt No. Permit No, Issu nce Datb Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 8520 <br />