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Applications Will Be Processed When Submitted ProperlyCompietea. rse sure rvoryrr •+rr•�- <br /> APPLICATION <br /> FOR OFFICE USE: <br /> •�� (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application Is <br /> made in compliance w t S n JOa vin Co n y Or ance No. 1 62 jand the rules and regulations of the San oa vin Local�Hevalth District. 4 <br /> �' Co ��r Iy City/Town <br /> Exact Site Address I ' r <br /> Phone <br /> Owner's Name D City <br /> Address <br /> License' Business Phone_ <br /> #�— <br /> Contractor's Name O Z. f <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation-Insurance N❑ <br /> .,surrance on With SJLHD? Yes \ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION 11DESTRUCTIO1� <br /> WELL CHLORINATION ❑ WELL ABANDONMENnnTrr❑ OTHER PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ /,M Oro <br /> FIrz <br /> DISTANCE TO NEAREST: Septic Tank sewerLines Pit Privy <br /> Gess ool/See page Pit Other <br /> Sewage Disposal Field p p g � <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE E OF WELL <br /> i, ❑ INDUSTRIAL �CAtsLE TOOL Dia. of Well Excavation <br />' ❑ DRILLED Dia, of Well Casing <br /> E ❑ DOMESTIC/PRIVATE Zr <br />� ❑ <br /> ❑ pMESTIC/PUBLIC DRIVEN Gauge of Casing � <br />" 4a IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> E] CATHODIC PROTECTION '❑ ROTARY Type of Grout <br /> ❑ DISPOSAL '❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> El State Work Done t <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> I I, Describe Material and Procedure <br /> I I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k 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 a person in such manner as to become subject to workman's compensation laws of California." <br /> ntracto hiring or s ant cling signature certifies the following:"I certify that in the performance of the work for which this „ <br /> permi .'s is ued, I sh m y p ns subject to workman's compensation laws of California." <br /> ' will call r In ecti for to lying and a final inspection. <br /> Title: <br /> i V Date: "�✓ 1 <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> k FOR DEPARTMENT USE ONLY <br /> • PHA Date <br /> i Application Accepted By <br /> Additional Comments: hese I11 Final In ection <br /> Phase 11 Grout Inspection l Date ��`-- <br /> Inspection 8y Date Inspection By 'p/"� <br /> NIT - .❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By Jury 31 <br /> Fee Is Due: ❑ ANNUALLY - ❑ PERU REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> 4 PENALTY <br /> OTHER <br /> OTHER <br /> 1Permit No. Issuan Da Mailed Delivered <br /> Received by Date if Receipt No. <br /> 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,3 <br />