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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> If ffLlo 1grItX (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT � <br /> (COMPLETE IN TRIPLICATE)�, (�' S . Vie¢iS E,� WATER QUALITY &10—0-51 0 <br /> Appl ication is hereby made to the San J oaqui in Local Health D istrict for a permi t to construct and/or I nstal I the work herein descri bed.Th is appli cation is p <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and rQgulations of the San Joaquin Local Health District. <br /> Exact Site Address �� J19�r aM 40 A�1 4tY City/Town <br /> Owner's Named Phone O(7 <br /> Address U CSG �- City— <br /> "'Contractor's <br /> ity ' <br /> Contractor's Name , License# Business Phone "' <br /> _ <br /> Contractor's Address = Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit�SJ D? Yes,�� No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN C1 RECONDIT ION <br /> C] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRN r <br /> REPLACEMENT[] <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> " I i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL. Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 19 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal InstalledI <br /> PUMP INSTALLATION: Contractor wov <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: C1 State Work Done Lor <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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. 0 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspectio 0 o ro Ing nd a final inspection.. <br /> Signed X <br /> t�r6� Date: <br /> (Draw Plot in on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III lnal Inspection <br /> Inspection By Date Inspection By Date <br /> I Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE �/C <br /> � <br /> F LESS <br /> IY4 PRORATION <br /> PLUS <br /> j PENALTY <br /> OTHER <br /> OTHER y <br /> Received by Date Receipt No. Permit No. Is uan a Date Mailed elly ed <br /> 'i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />