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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> a -- (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE)�-.Z"rTLas(gas'' -, 4sw �LITY <br /> 2-0Oo- �"u <br /> Application is hereby made to the San Joaquin Local Health District f rmirto construct and/pr install the work herein described.This application is <br /> made in compliance with San J iprCounty Ordina 5 No.1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name F Phone J C <br /> Address -5 City _ ! <br /> Contractor's Name License Business Phone " sj <br /> Contractor's Address t . .- mergency Phone <br /> Is Certificate of Workman's Compens tion Insurance on file With JLHD? Yes -�� No ('�y <br /> TYPE OF WORK (CHECK): NEW 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 /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> '❑ IN IAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> _❑ DISPOSAL ❑ OTHER Other Information <br /> `❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P.—! � , <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done CMD <br /> N �1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate,Depth <br /> . .� 1 <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 /> Homeowner 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 )or a Grout4ns ction prior to grouting and a final inspection. <br />� f <br /> Signe Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY ~ <br /> PHASE I <br /> E Application Accepted Date Z/-3'' `� <br /> Additional Comments: <br /> Phase II Grout Inspection lase Ili Fi InspI Ion <br /> Inspection By Date Inspection By i7ate <br /> ❑ January 1 &Received By January 31 July 1 &Received By JuVy 31 <br /> Fee is Due: 13 ANNUALLY ❑ PER UNIT 11 PER SITE El EACH <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ AMOUNT <br /> �ad <br /> FEE <br />' tESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER <br /> i <br /> r <br /> OTHER <br /> 057377 <br /> 1 'SC7 <br /> } p Receipt No Permit No. - Is anc ate Mailed Delivered "� "" <br /> Received by -� Date P <br /> �. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZE 11 AVE.,P.O.Box 2009 STOGKTON,CA,96207 <br /> f <br />