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App r i n y l8 rocessed When mlttea ProperlywHINrW«u• <br /> FOR OFFIC,Fi-USg:_w2 $� APPLICATION <br /> ( r Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> �t1 <br /> gF4,At�IMENTAL HEALTH PERMIT <br /> A,L 1 )p ,'% S 1 CJ WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) S �A LV� ribed.This application is <br /> Application is hereby made to the Sariirrd in Local Health District for permit to construct and/or install the work herein desc <br /> made in compliance with Sa J a uin County Ordinance No. 1862and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address / U <br /> Owner's Name Phone <br /> d� a t-' <br /> Address <br /> Contractor's Name k"' <br /> License# Z) Business Phone -aZ -7 <br /> Contractor's Address ) ✓" Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes LVA No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ p�, <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Ci DOMESTIC/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 /> A` <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor <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 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 forwhich 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> _1� <br /> I wil for a rout In tion ' r to grouting and a final inspectio <br /> Signed X w Title: ! Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 t° Date -`a a- <br /> Application Accepted B - <br /> Additional Comments: <br /> Phase II Grout Inspection Pha527 <br /> ection <br /> Inspection By Date Inspection.By Date <br /> Fee Is Due: El ANNUALLY ❑ PER UNJ ❑ PER SITE ❑ EACH El January 1 & A�fvedBy'oianuary 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3a� o s�� 3/ � � <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.60■2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />