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{ Applications Will Be Processed When Submitted ProperlyCompletes tsesure IvarJ+ •��--rr - l! / <br /> FOR oFFJcE usE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRON*EE 1'1SALTH PERMIT <br /> (] O Ltr-4% -- A f yALTTY <br /> (COMPLETE IN TRIPLICATE.�..Applicationishereby "*dtoifrittt�JuinLacalHealth40m,a permit tocanstructand/orinstallthe work herein described.This application is <br /> made in complia l with San Joaquin County Ordinance No. 1862 and the ;i es.and regulations of the San Joaquin Local Health District. <br /> 41 �t City/Town <br /> Exact Site Address 16 _Phone 1 •7 Z /,1 <br /> � � <br /> Owner's Name hN }' City <br /> Address !� s License# Business Phone <br /> Contractor's Name - <br /> � - ,�e,E, Emergency Phone <br /> Contractor's Addrels� 4___ No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK NEWELL <br /> ELM-DEPEN❑❑ OTHERO❑ ITIO PUMP INSTAL AT ON®"' UMP REPAIR <br /> WELL CHLORINATION <br /> REPLACEMENT❑ j�j b pit Privy <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines esspool/seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line e44 Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND STRIAE <br /> El TOOL Dia. of Well Excavation f`y <br /> ❑ DRILLED Dia. of Well Casing <br /> 0S­DOMESTIC/PRIVATE <br /> Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC C3 DRIVEN <br /> ❑ <br /> 1:1 IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> N-VOTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> [I DISPOSAL ❑ OTHER <br /> Surface Seal Installed By' <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor r s <br /> Type of Pump ` H.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> Home owner 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. , <br /> Title: Date. <br /> Signed X <br /> (praw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE b Da;- <br /> ft <br /> Application Accepted By <br /> Additional Comments: , ase-11 I al Inspection <br /> ha r Inspect on at r` / <br /> Inspection By <br /> At <br /> o Inspection By <br /> ❑ ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 E] July 1 &Received By July 31 <br /> Fee l5 Due: El ANNUALLY PER UNIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERIf <br /> Received by Date <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 16tH E.H,gZELTDN AVE.,P.O.Bot 2009 STDCKTON,CA 9520 <br />