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Applications Will Be Pro960ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLIWfON f <br /> (For Non-Transferable, Revocable,Suspendable) - I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Appl ication is hereby made to the San Joaqui Loc al Health District fora permit to construct and/or install the work herein described.This application is <br /> r- <br /> made in compliance with an Joaquin Coun yOr inance No. 1862 and the r les and regulations of the San Joaq in Loll Health D' trigt. t <br /> Exact Site Address r Q�- 4.,J;YAw-1 City/Town <br /> Owner's Name Phone <br /> Address City I <br /> Contractor's Name W. Licerfse# .L:�r:3 7z<r_­Uusiness Phone m <br /> Contractor's Address Emergency Phone + <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION.O PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field .-Cesspool/Seepage Pit Other ! <br /> Property Line Private Domestic Well Public Domestic Well I <br /> INTENDED USE TYPE OF WELL G <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 0 <br /> ❑ DISPOSAL ❑ OTHER Other Information J <br /> ❑ GEOPHYSICAL 5urface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P• <br /> PUMP REPLACEMENT: ❑ State Work Done �} <br /> t <br /> PUMP#4W*44W: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <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 <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:"!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 wilYcall for a Grout Inspectia r gr uti and a final inspection. <br /> 6 A <br /> Signed X itle: � Date: <br /> (Draw Plot an on Reverse Side) <br /> �FOR DEPARTMENT USE ONLY <br /> PHASE I �_�4(� <br /> Application Accepted By <br /> Date 6� <br /> Additional Comments: <br /> ` Phase 11 Grout Inspection Phase III F! nspection i <br /> Inspection By Date Inspection By Date I <br /> Fee 15 Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> - - REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r RASE EXPLANATION` DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ^ <br /> PRORATION + <br /> PLUS l <br /> PENALTY s <br /> d <br /> OTHER # r` <br /> OTHER <br /> C�� t �� — 7 ` �� <br /> Received by Date I Receipt No.. Permit No. Issuance Date Mailed Delivered � _f <br /> •�.. APPLICANT—RETURN ALL COPIES TO:'91-ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,,P.O.Box 2009 STOCKTON,CA 95201 <br />