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Applications Will fie Processed When Submitted Properly <br /> ' APPLICATION <br /> I FOR,QFFICE USE: <br /> — ,: (For Non-Transferable, Revocable,Suspendable) pump&WELL <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application Is h� <br /> made in compliance wi h Sa Joa uin Co my Ordinas:ae No. 1862 and the rules and regulations of the San oQgpui a �tilth District. W <br /> City/Town ' U <br /> Exact Site Address <br /> F. �. Phone / V <br /> Owner's Name _ 4�7 City Ga <br /> Address <br /> License��Bu I ess Phone <br /> r's Na <br /> Contractome - <br /> .� Emergency Phone <br /> Contractor's Address . � No !1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑❑ OTHER RECONDITION <br /> ❑ ITI PUMP INSTALLATION N� PUMP REPAIR❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � _Sewer Lines Pit Privy <br /> Cesspool/Seepage Pit Other <br /> t Sewage Disposalfield <br /> Property Line—"— Private Domestic-Well <br /> 0/ Public Domestic Well <br /> INTENDED USE TYPE OF WELL D �' <br /> ❑ INDUSTRIAL CABLE TOOL Dia- of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ El-DRIVEN`DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> i ❑ <br /> Type of Grout <br /> CATHODIC PROTECTION 11ROTARY <br /> { <br /> ❑ DISPOSAL } ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal- istalled By: <br /> PUMP INSTALLATION: ( Contractor H P / <br /> - — Type of Pump " ,. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> C <br /> PUMP REPAIR: ❑ State Work Done <br /> F U <br /> Well Diameter Approximate <br /> DESTRUCTION OF WELL: r <br /> Describe Material and Procedure <br /> k <br /> j 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:"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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> + i will call for aG_out Inspection prior.to grouting and a final inspection. <br /> Signed X w Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> f Additional Comments: Kase III Final Inspection <br /> Phos 1 Groul 1"nspectian ; j ,f�; Date —Z-fl, <br /> k Inspection By Date �( Inspection By <br /> �. <br /> Fee IS Due: ❑ ANNUALLY ❑ PERU CT ❑ PER 517E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> _BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BRSE EXPLANATION <br /> - DATE DATE REMITTED AMOUNT <br /> © <br /> .FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r - <br /> 'OTHER - - <br /> Received by Date <br /> Receipt No. Permit No. ssua ce Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ..�; <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - �-_ - <br />