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Applications Will Be Processed When Submitted Properly Completed. Be Sure To ign TheApplication. <br /> 'FOR OFFICE USE: APPUCAT{ON <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT y <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _ n <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San.1.0a in County Ordinance Ito. 1862 and the ru d regulations of the San Joawi Local e�Ith.District <br /> Exact Site Address J J� City/Town <br /> Owner's Name I- // Phone <br /> Address City l <br /> Contractor's Name icense Business Phone / <br /> Contractor's Ad Iii Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLH_D? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL MDEEPEN ❑ RECONDITION 13" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Lam- PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> -v B�OJJ <br /> Property Line Private-Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL rJ + L /. <br /> ❑,�3, IN/DUSTRIAL 11 CABLE TOOL Dia. of'Well Excavation G� A <br /> IIYDOMEST IC/PRIVATE is DRILLED Dia. of Well Casing �d L <br /> ❑ DOMESTIC/PUBLIC ❑.DRIVEN Gauge of Casing —� - , � <br /> ❑ IRRIGATION ❑ -GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION W-4-OTARY Type of Grout ere <br /> ❑ DISPOSAL ❑ OTHER. Other Information <br /> ❑ GEOPHYSICAL $urfac a Install d By: / <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work g�fe <br /> DESTRUCTION OF WELL: Well Diamet pproximate 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 /> 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'cer y that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to,workman's compensation IaWs of California."".( <br /> I 'Ilea for -G ou spection prior to grouting and a final inspecti n- ' § J <br /> Signed X Title:/ ' Date: <br /> (Draw Piot Plan on Rev se Side) Z� <br /> FOR DEPARTMENT USE ONLY <br /> ;. <br /> PHASE I -Date,� 3 6� <br /> Application Accepted By } z <br /> Additional Comments_ <br /> Phase II Grout Inspection pecio <br /> _Zi <br /> Inspection By Date inspection By Date <br /> Fee Is Due: C1ANNUALLY ❑ PER UNIT ElPER SITE 'ElEACH ' ❑ January'1 &Received By January 31 - 0-July 1 &'Received^By,iluly,31...}, <br /> �.,,, . . REMIT <br /> BILLING REMITTANCE -1 $ AMOUNT DUE CHECKED <br /> BASE zEXPLANATION DATE ��� DATE;_ REMITTED,. _ <br /> ?•, �:^°i _ /��9 "j��...,1.. >.+: ' "AMOUNT. <br /> FEE' r-/ 6OZ <br /> LESS T'�i r( ��" »-� f` t+fl74 Ads roppdr-I,1 46 <br /> r PRORATION - <br /> _. _PLUS 1✓elr <br /> PENALTY... y;r U✓ <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Delivered - > <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />