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Applications WiWBe Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S J aq 'ntunty O 'nance No. l 62 and thl r es and regulations of the San Joaquin Local Health District. <br /> Exact Site Address.. , City/Town j <br /> Owner's Name Phone 7=[163 <br /> Address ! City <br /> Contractor's Name _ �_j 11`J License#� Bus- ess Phone_ 3�?3 <br /> Contractor's Address - ` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes __ No <br /> TYPE OF WORK (CHECK): NEW WELL 0. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C <br /> I Sewage Disposal Fielder Cesspool/Seepage Pit Other <br /> — <br /> Property Line. Private Domestic Well Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation s. 1 <br /> t )(DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION OROTARY Type of Grout _ r <br /> ❑ OTHER Other Information s b6,f —c <br /> 11 DISPOSAL � f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 01"fq!mei- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> t. DESTRUCTION OF WELL: 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 laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:A 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 /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> i I wi r a Grout Inspecti n prior to grouting and a final.inspection. <br /> E Signed X Title: Date: `" <br /> ( Plot Pl51 <br /> an on Reverse Side) <br /> k ' <br /> F R DEPARTMEN USE ONLY <br /> PHASE <br /> t Application Accepted By _ Date <br /> Additional Comments: <br /> �rout n e a s e IInspection y �— -7 I sp ction By bate j120 <br /> Fee Is Dii ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BASE _ EXPLANATION BILLING_ REMITTANCE $ A OUNT DUE . CHECKED <br /> �' DATE DATE REMITTED AMOUNT <br /> FEE <br /> t _44- <br /> LESS <br /> PRORATION ' <br /> PLUS ' <br /> PENALTY <br /> OTHER '•�,' _.i,r, y - r <br /> OTHERS <br /> Received by Date Receipt No. Permit No 7 Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />