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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. A <br /> r FOR OFFICE USE: APPLICATION <br /> t <br /> (For Non-Transferable, Rev6cabte,4 Suspendable) PUMP& WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein.described.?This application is <br /> iance 7 <br /> made in complwi San Joa in Co ty Ordin n e No 1 62 and the rules and regulations <br /> Exact Site AddressLl 17 of the San o uin Local Health District. <br />` <br /> City/Town <br /> Owner's Name <br /> Address aa4. ;�: ;s z ,r,., Phoney <br /> ity <br /> Contractor's Name /L. "' License /, <br /> 31�?�*Business Phone` <br /> Contractor's Address -�� I <br /> '' rEmergency Phone's . - �, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes __ ' No <br /> TYPE OF WORK (GHECKJ: NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - 06 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ M- <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines f <br /> Pit Privy `— <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well_,<Q Public Domestic Well <br /> INTENDED USE TYPE OF WELL M <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑'DRILLED Dia. of Well Casing 4 <br /> ❑ DOMESTIC/PUBLIC _ ❑ DRIVEN Gauge of Casing <br /> oe Ile C4 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout.5eal 1 <br /> 13CATHODIC PROTECTION I •ROTARY Type of Grout <br /> C1DfSPOSAL ❑OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H P. <br /> PUMP REPLACEMENT. 11 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ? Diameter Approximate Depth <br /> Describe Material and.Procedure <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 /> .-r <br /> Horne 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 for which this <br /> permit is issued, I all employ p sons subject to workman's compensation laws of California." <br /> t II all t r a rout- spec"o prior to grouting and a final inspection. r <br /> Signed X <br /> Title: Date: 1v Q <br /> (Draw Plot Plan on Revers Side) <br /> PHASE I <br /> FOR DEPARTMENT� USE ONLY <br /> � `' <br /> Application Accepted By - -Dae, --mw, J R t <br /> Additional Comments: y !-- Date f <br /> Phase I I Gro t Inspection � '' ' <br /> Pha .III Final I ection ` <br /> Inspection By '�! Date s- spection By Date 2j1a' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 El July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> 3 AMOUNT <br /> ` D O <br /> LESS - <br /> PRORATION L <br /> PLUS <br /> PENALTY" <br /> OTHER <br /> OTHER - <br /> Received by Date Receipt No. - .Permit No. I Issuan a Date <br /> Mailed y Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> T,9P C4_ �Lub 1601 E.HAZELTON AVE.,P.O.Box 2pp9 STOCKTON,CA 95201 <br />