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ppIcarlonsWill Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> y I (For Non-Transferable, Revocable, Suspendable) , <br /> Yl <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ^L PUMP WELL <br /> (66PLETE IN TRIPLICATE) v WATER QUALITY �-� Z-0 v 10.4 <br /> Application ishereby rttadetothe SanJoaquin Local Health District fora permit toconstruct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 d the rules and regulations of th San Joaquin Local Health District. <br /> Exact Site Address ;II,IIIOW wwo / <br /> Owner's NamePhone 1 <br /> Address <br /> City Z- r <br /> Contractor's Name License#,Zai' ` =_� — <br /> /,� _ Business Phone <br /> Contractor's Address (I(� SI� ' _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No f <br /> TYPE OF WORK(CHECK): NEIN WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewalge Disposal Field Cesspool/Seepage Pit Other <br /> Prop rty Line Private Domestic Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia, of Wel! Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ?C'DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casings <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal r \' <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By; <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. i <br /> } ] <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ? <br /> j Approximate 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 fallowing:"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 orsub4. <br /> lcontracting signature certifies the following:"I 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 will call for a Grout In p� tion prior to grouting and a final inspection. <br /> Signed X Title: aDate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE RTME T USE O Y <br /> PHASE I <br /> Application Accepted By <br /> _ Additional Comments: <br /> ,p ..Date <br /> Ph a II� r u I spection -Phase III Final Inspection <br /> Inspection By Date 7 _g Inspection By Date . <br />^ �I <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE i Ex PLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEET AMOUNT <br /> LESS �F <br /> LI <br /> PRORATION <br /> PLUS <br /> PENALTY_,�..- <br /> OTHER <br /> OTHER <br /> Received by e <br /> DatI Receipt Nb. Permit No. - I uance Date Mailed <br /> I! Delivered < � <br /> APPLICANT—RETURN ALL COPIES 70; - ENVtRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �+' <br />