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FOR oFFicE USE: ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELLENVIRONMENTAL HEALTH PERMIT / <br /> l <br /> (COMPLETE IN TRIPL "ATE) 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 } l' <br /> made in compliance with San Joaquin County Ordinance No. 1852 and the rule an regulations of the San <br /> app tion is <br /> Exact Site'Address >� ,�� _ q in Local Health District. � ' <br /> Owner's Name <br /> -y/Town <br /> Address Phone - r�Z� <br /> Contractor's Name City <br /> Contractor's Address ��J,,License# ,3 Business Phone <br /> is Certificate of Workman's Compensation In urance on File W��HDA erg ency Phone J <br /> TYPE OF WORK (CHECK); NEW WELL DEEPEN ❑ Yes �� No <br /> WELL CHLORINATION ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank <br /> -sewer Lines - Pit Privy ---� <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit r <br /> Property Line Well Other <br /> Private Domestic W <br /> INTENDED USE Public Domestic Welt <br /> INDUSTRIALTYPE OF WELL <br /> ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE Dia. of Well Excavation <br /> ElDOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN <br /> El IRRIGATION Gauge of Casing [�t1 <br /> 11 CATHODIC PROTECTION <br /> GRAVEL PACK Depth of Grout Seal <br /> ROTARY <br /> ❑ DISPOSAL ❑ OTHER Type of Grout <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: Surface Seal Inst <br /> Contractor alled By: i <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done H.P. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> N <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:"I certify that in the performance of the work for which this permit r lr <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 prior to grouting and a final inspection. <br /> f <br /> Signed X <br /> it1e: <br /> (Draw Pf Ian on Reverse Side) Date: <br /> PHASEI <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> ...� i <br /> Application Accepted By CJ <br /> Additional Comments: d"e Date0 <br /> P se I Grout Inspection <br /> Inspection By �;�(• ` Phase jyFinal Inspection <br /> Date Inspection By 1000, <br /> Date <br /> Fee Is Due: ❑ ANNUALLY El PER uNIT � <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received 8y Jvly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER ti IF <br /> rn <br /> "��- 8 � 3 <br /> Received by ate _11Receipt Np_ <br /> Permit No Issuance Date- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered <br /> 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCK7[]N cn n- <br />