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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> p `� <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY ., .,4: i. -. 11' . <br /> RIPLIC <br /> (COMPLETE IN TATE) <br /> Application is hereby made to the San Joaquin Local Health Districtiora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin.Count Ordinance_No. 1862 and they rules and regulations.of the,San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address �0 <br /> f Phone' ' " . }` `•, <br /> Owner's Name <br /> Address <br /> 7" <br /> License#` B <br /> Contractor's Nam <br /> �• ;.w" *t <br /> Emergency Phone" I <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK)'. ��WE BANDONMENT ❑❑� OTHER ITI Pl❑M P�INSTALLATIDESTRUCONO❑❑ PUMP REPAIR <br /> WELL CHLORINATION ❑ <br /> REPLACEMENT❑ + <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ' Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic.Welt Public Domestic Well <br /> � INTENDED USE <br /> TYPE OF WELL I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 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 ❑ ROTARY Type of Grout <br /> f ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL IF <br /> Surface Seal Installed <br /> Contractor fQ 6�1 ` lar: T <br /> PUMP INSTALLATION: H.P. ! lam' <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done . —� <br /> PUMP REPAIR: IN State Work Done - - <br /> DESTRUCTION OF WELL: <br /> Well Diameter y Approximate Depth <br /> ~ <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 /> ` }come 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." f <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 III call for Grout Inspe on p i r grou and final inspection. , <br /> Itle: Date: <br /> Signed <br /> (Draw Plot n everse Side) • <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted <br /> Additional Comment hale 111 Inst I pection <br /> Phase II Grout Inspection pate �� 2 <br /> Inspection By- <br /> E]Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received REMITBy uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED , AMOUNT <br /> FEE s0�� <br /> LESS +s <br /> PRORATION - - <br /> PLUS Y -r <br /> PENALTY , <br /> OTHER - - <br /> OTHER <br /> pate Receipt No. Permit No. - Iss ance a e Mailed Delivered - <br /> i Received 6y 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P£RMITlSERVICES <br />