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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplication. i <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT E <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) l <br /> al HealthDistrictlorapermittoconstructand/orinstallthework herein described.This application is <br /> Application is hereby made to the San Joaquin Loc <br /> I <br /> made in compliance with San Joaquin County rdinanc No. 1882 and the r sand regulations of the San Joa�lin Loc eal h District„ I t <br /> w, 'Exact Site Address_ <br /> Z f City/Town � k <br /> Ir Owner's Name � �' Phone ��� <br /> Address 4 City C ' <br /> �'ry9 C <br /> Contractor's Name ® License Business Phone <br /> Contractor's Address .2 ;7__9,; - � Emergency Phone eer l <br /> Is Certificate 9f Workman's Compensation Insurance on File With SJLHD? Yes ' No G' .i <br /> TYPE OF WORK (CHECK): NEW WELL&DEEPEN 13RECONDITION 11DESTRUCTION❑ J ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.❑ - OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑_ _ _ - _- - _ - ' M <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy g' <br /> O a f Cesspoo page Pit Other s <br /> Sewage Disposal Field P P 9 <br /> Property Line66::� Private Domestic Well Public Domestic Well <br /> TYPE OF WELL l <br /> INTENDED USEf� <br /> El INDUSTRIAL----�- �-. , - w : -❑ CABLE TOOL Dia. of Well Excavation <br /> •o UVMESTIC/PRIVATE 41 <br /> ❑ DRILLED Dia. of Well Casing i <br /> ❑ .DOMESTIC/PUBL1� ❑ DRIVEN Gauge of Casing; <br /> _ ! <br /> ❑'IRRIGATION _ 4 `-❑ GRAVEL PACk Depth of Grout Seal i. <br /> "❑ CATHODIC PROTECTION' NARY Type of Grout '�— <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13GEOPHYSIA .,. Surface Seal Installed B 777 <br /> PUMP INSTALLATION: Contractor? <br /> ��. Ty.pe:ot Pump H.P. <br /> �. <br /> - rv, <br /> PUMP REPLACEMENT: - ❑ State Work Done' <br /> PUMP REPAIR: ` „ ' - ❑ State Work Donees <br /> DESTRUCTION OF WELC _ Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application and that.the{work will be,done in accordance with San Joaquin County I <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, 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 I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will I for a Grout Inspection prior to grouting and a final inspection. S <br /> Title: <br /> Signed X Date: <br /> r <br /> draw Plot verse Side) <br /> (9 ��� ARTMENT USE ONLY <br /> PHASE i�`�? v / Date 7 <br /> Application Accepted By <br />,t Additional Comments: <br /> P s 1 Gro t spection rS v � as III inal l spection <br /> Inspection By <br /> Date ` Inspection Date <br /> Fe@ Is Due: ❑ ANNUALLY ❑ PER UN T ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I gggE EXPLANATION BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> DATE DATE .REMITTED AMOUNT <br /> o O a ca �I <br /> FEE , <br /> LESS <br /> i PRORATION <br /> PLUS <br /> PENALTY ,. <br /> OTHER ' <br /> OTHER <br /> te <br /> Received by b, '; ate Receipt No. Permit No. <br /> Issuance Daa Mailed Delivered <br /> -7691 E.HAZEL AVE.,P.O-Box 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETUAN ALL`t'OPIE5 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t <br />