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Applications Will Be Processed When Submitted.Properly Completed. Be Sure To Sign The Application. j <br /> FOR OFFICE USE: APPLICATION `3 <br /> L (For Non-Transferable, Revocable,Suspendable) <br /> w ,� , PUMP &WELL <br /> �' ENVIRONMENTAL HEALTH PERMIT <br /> F (COMPLETE IN TRIPLICATE} WATER QUALITY , <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 t <br /> made in compliance with San_Joaquin County Ordinancb No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address s ` ` d' ' City/Town 6,k_ t <br /> Owner's Name WA 7Afiy 817 <br /> as, Phone <br /> Address ��� i; A4PJ#& City .// <br /> Contractor's Name CJ W 1. 4 f�f�/ CO,/X/Ciucense# Business Phone �� � <br /> Contractor's Address 7S& ��� i Emergency Phone <br /> k Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No T <br /> i TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONZ? DESTRUCTION❑ <br /> r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 4 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 pia. of Well Casing �f <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout d` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection pri r to grouting and a final inspection. " <br /> Signed �[\ `� Title: - /r `,, Dater% r�i"� I. <br /> a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMEN USE ONLY <br /> PHASE I ,7 <br /> Application Accepted By Date I <br /> Additional Comments: <br /> Pha a 11 Grout Inspection Phase III Final Inspection <br /> r <br /> Inspection By Date Inspection By a !IjDate-3 <br /> 1 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Nr PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE M <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHER <br /> r <br /> OTHER <br /> 79 <br /> Received by Date Receipt No. - Permit No. Issuance i5ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES W 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f <br />