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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ''(For Non-Transierable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin CcPty Ordinance lo. W the rules and regulations of the San J in Local Healt istriot, <br /> Exact Site Address City/Town`__ h a- )4 r T <br /> Owne'r's Name Phone <br /> Address C� y .�. .�5,.. 4 City: , <br /> Contractor's Na'A I AticensP &v �� Business Phone, 4: <br /> Contractor's Address -, i;=pcy Phone:. x. ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ " RECONDITION C3DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®PUMP REPAIRED <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ' Sewer Lines4_ Pit Pr"vy <br /> Sewage Disposal Field A/" �e-,_ Cesspool/Seepage Pit Other <br /> Property Line A� Private Domestic Well ---T Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> e <br /> ,❑� INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,r f <br /> z DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ,❑r��GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I�rF30TARY Type of Grout ^ <br /> 11 DISPOSAL € ❑ OTHER Other Information �+ -17 0 _ <br /> ❑ GEOPHYSICALS face Seal Installed .By: , M <br /> PUMP INSTALLATION: Contractor • t' , 4 <br /> Type of Pump ' H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter # Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 certify that in the performance of the work torwhich this <br /> permit is issued. I shall emploW <br /> to workman's compensation laws of California." <br /> will call for a Grout ctg and a final-inspection. <br /> Si ned Tit1e� �Y f��n��� Date:w Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> P - t <br /> Application Accepted By Date 1� i1� &L <br /> Additional Comments: <br /> h p rout Inspection' ,,��,�.P��h " III Final Inspection <br /> ' Inspection By,4 Date . � Inspection By /i��'X Date <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE' ❑ EACH -- ❑ January 1 7Received By Januar ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> { BASE EXPLANATION DATE DATE TT <br /> AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 6 0 <br /> LESS -- <br /> PRORATION 41 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - •+ - <br /> Received by k. --Date ,rte.. ,.,,Receipt No. w Permit No. ., issuance Date —Mailed. . Delivered <br /> APPLICANT—R ETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />