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._�01, <br /> Applications Will Be Processed When Submitted Properly <br /> FOR OFFICE USE: APPLICATION - <br /> `�, (For Non-Transferable, Revocable, Suspendable) PUMP gt WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaqui n Local Health District for a permit to construct and/or instal;the work herein described.This application is <br /> made in compliance with Sa Jo uin C u ty Ordinance No..l 62 and the rules and regulations of the San Joaqu.F Local Health District. <br /> City/Town j <br /> Exact Site Address / <br /> Phone r <br /> Owner's City 10 t <br /> Address Bu 12 es Phone , <br /> fj License <br /> Contractor's Name <br /> G Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL.. DEEPEN ❑ RECONDITION 1:1 DESTRUCTION <br /> WELL CHLORINATION ❑ WELL AB+NDONMENT ❑ OTHER 13 OTHER <br /> INSTALLATION ISI PUMP REPAIR <br /> REPLACEMENT❑ // f Pit Priv <br /> DISTANCE TO NEAREST.. Septic Tank v Sewer Lines y , <br /> Cesspool/Seepage Pit Other <br /> t Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 Excavation Well Er( <br /> Dia. of Wexca —�/ _ <br /> ❑ '� CABLE TOOL <br /> INDUSTRIAL <br /> 1:1DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE <br /> DOMESTIC/PUBLIC ❑ DRIVEN """'—" "Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout a <br /> C3 DISPOSAL ❑ OTHER Other Information U <br /> 5 Surface Seal Installed By: y <br /> ❑ GEOPHYSICAL <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: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby certify that I have prepared this applicatiori 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, 1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i{ i <br /> I will all for rout Inspection pr gr r to grouting and a final inspection. <br /> t Date: <br /> Title: �� <br /> Signed X <br /> {Draw P lot Plan on Reverse Side} <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I L�� Date <br /> i Application Accepted By <br /> Additional Comments: h s HI Final Inspection <br /> e II Grout Inspection Date fii✓t <br /> Inspection By <br /> Date 1 Inspection By <br /> t' <br /> . PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 EJ July 1 &RecervedT my 1 <br /> Fee Is Due: 13 ANNUALLY REMIT <br /> BILLING REWTTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATVON DATE DATE REMITTED AMOUNT <br /> s FEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> k <br /> OTHER j <br /> OTHER ! r <br /> ,. .. Issuance Date Mailed Delivered <br /> Date � <br /> Receipt No, Permit No. <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br /> APPLICANT--RETURN ALL COPIES To;, ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />