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atio�nss�Will B ess ten Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF!1; <br /> No 22 iff APPLIC+ATION(For Non-Transferable, Revocable, Suspendable) <br /> pPH L VIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ®ISTR0 WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora pe'rmitto construct and/or install the work herein described.This application is <br /> made in compliance with San Jouin County Ordinance N� 1862 and the rules and regulations of the S Joaquin Local Health District. <br /> Exact Site Address tO `3� City/TownD �m i <br /> Owner's Name 7- - Phone <br /> Address 0—Y r i5� City C1n1 <br /> Contractor's Name a G\-\CL A 6 License# �h-v Business Phone 24Q) , <br /> Contractor's Address 4 N 71W - Emergency Ve a'14,2- � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION'S PUMP REPAIR❑ d <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> e <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 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 /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: contractor YNO {{ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: +State Work Done <br /> PUMP REPAIR: ❑ State Work Done d <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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:"1 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 for which this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." <br /> I wil or Grout Inspection pri grow ' g an final inspection. <br /> Signed X c.- itle: Date: <br /> . (Draw,Plot Plan on Reverse Side) <br /> _ 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � C)S <br /> Application Accepted By �/v Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph e I Final inspection <br /> Inspection By 11+. Date Inspection By Date fo <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> - B#LLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE 'DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEED <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER }� <br /> Received by - Date Receipt No. Permit No Issua ce Date Mailed- Delivered t - <br /> i `APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,RO.,Boa 2009 STOCKTON,CA 95201 <br />