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Appilcations Will Be Processed When Submitted Properly comPreze.,. <br /> APPLICATION I'unnP&WELL <br /> SLI <br /> 1R O ICE USE: For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> n <br /> WATER QUALITYlication is <br /> ,;OMPLETE IN TRIPLICATE) Districtfora permitto construct and/or install the wor <br /> 1862 and the rules and regulations of the San Joaquin oval Health District. <br /> a lication is hereby made to the San Joaquin Local Health Dosk herein described.This application <br /> pP <br /> made in compliance with San Joaquin County r inan e 0V f- City/Town <br /> Exact Site Address Phone <br /> s 4 <br /> Owner's Name City <br /> Address License#•2 � Business Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address NO - <br /> is Certificate of Workman's Compensation insurance on File❑With SRECONDITION No <br /> is <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT 13 1 �-f Pit Privy <br /> Sswer Lines Other <br /> DISTANCE TO NEAREST: Septic Tank / Cesspool/feepage Pit — � <br /> Sewage Disposal Fiyld public Domestic Well <br /> Property Line Private Domestic Well II <br /> INTENDED USE TYPE OF WELL Dia, of Well Excavation <br /> 11 INDUSTRIAL <br /> INDUSTRIAL ElCABLE TOOL <br /> 11 DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE 13 DRIVEN Gauge of Casing r <br /> C Depth of Grout Seal <br /> IRRIGATION GRAVEL PACK <br /> ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION 13 OTHER Other Information r— <br /> ❑ DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter (� <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:"t certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such�manner ies tas fol owin become'1 certify thasubject to t illrthe performance oflthe on lwork forwws of h California."h this <br /> g,, <br /> Contractor's hiring or sub-contracting signature <br /> permit is issued, 1 Shall mpioy per ns subject to workman's compensation laws of California." <br /> 1 1 r a G Ut pecti for to grouting and a final inspection. <br /> Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IDate �� <br /> Application Accepted By <br /> Additional Comments: P ase 111 Final Inspection <br /> h se li Grout Inspection Inspection By Date <br /> inspection By Date <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATIONDATE DATE REMITTED AMOUNT <br /> [ <br /> FEE- �� 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> .-OTHER <br /> 3 1ss nct Mailed Delivered <br /> eceived by Dale <br /> Receipt No. Permit No. 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> R <br />