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Y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE usE: APPLICATION <br /> { <br /> t a (Fpr Non-Transferable, Revocable;Suspendable) PUMP&Wi=EL ,i' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) c8I S' WATER QUALITY. <br /> Application is hereby madeto the San Joaquin Local Health District for a.permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa uin cal Health Di rict. <br /> Exact Site Address s �� �� � ! �' City,Town C� <br /> Owner's Name t' � Phone <br /> IMPry ... Cit _. .. <br /> v,-�-. f <br /> Address License#' �Busine s Phone'' 4 Ve6 �' 4776 7 p <br /> Contractor's Name <br /> Contractor's Address ` Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File Wi _SJLHD? Yes No _ t <br /> TYPE OF WORK'(CHECK): NEWWELL❑ DEEPEN ❑' RECONDITION❑ DESTRUCTION❑ - <br /> WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR CR 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other, w <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL =- <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Wel Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 4 ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL t Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T C H.P. <br /> i J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done 40,4 rb <br /> DESTRUCTION OF WELL: Well Diameter Approximate-Depth <br /> Describe Material and Procedure <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 />` <br /> Homeowner 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 perform ance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 ill call for a Grout Inspecti n pri to gr <br /> i and inal Inspection. <br /> g . le: / Date: / y. <br /> Si ned <br /> (Draw Plot n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspectionh e III Fin Inspection <br /> Inspection By Date Inspection Date <br /> Fee Is Due: [3 ANNUALLY ❑.PER UNIT. ❑ PER SITE ❑ EACH `❑ January 1 &Received By nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE <br /> BASE EXPLANATION DATE ` s REMITTED <br /> . AMOUNT <br /> FEEW 1 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed– -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />