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ApplicW'Wris Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION . <br /> (For Non-Transierable, Revocable, Suspendable) / <br /> l PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> y OMPLETE IN TRIPLICATE) WATER QUALITY <br /> (C <br />° <br /> Applicationis 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 conitplianee with an Joaqu'J " County Ordinance No''1,862 and the.rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address " C2 �13`04� � w• _ City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# b290&3 Business Phone <br /> Contractor's Address mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Z/ No <br /> TYPE OF WORK (CHECK): NEW WELL ,-' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1:1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ` <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> EVDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing e- <br /> ❑ DOMESTIC/PUBLIC �❑, DRIVEN Gauge of Casing <br /> ❑ � <br /> IRRIGATION '"GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IVROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done.' <br /> PUMP REPAIR: ❑ State Work Done <br /> 1 DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 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 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 call for a Cpro Inspe tion prior to grouting and a final inspection. <br /> I Signed X Title: Dale: <br /> - A" <br /> (D w Plot Plan on Reverse ide) - - _. - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> f P a I Grout Inspection!) �3Y Phase III Final Inspection <br /> r Inspection By Date_sl' Inspection By 001 Date <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER&TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> 1 <br /> PENALTY <br /> i <br /> OTHER <br /> ' OTHER <br /> ,mom y�a� - ! a te I S a <br /> r <br /> 11ecenred6y I Dat Receipt No. Permit NoIssuance Date -' Mailed _ -Defivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952DII <br />