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m �A Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION 6ZZ Al � 1� 7- <br /> �� � <br /> FOR OFFICE'USE: ,f,% " <br /> } : (For Non-Transferable, Revocable, Suspendable) t /1 � PUMP&WELL , t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> .I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count rdi nce�lo. 18fi2 and t e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town ° <br /> r Phone <br /> Owner's Name <br /> Address 0 < City r <br /> Contractor's Name License��4� � Business Phone <br /> Contractor's Address Emergency Phone �.�! l —� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ��!' Noj <br /> TYPE OF WORK (CHECK): NEW WELL 5"1 DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL�ABANOONMENT ❑ OTHER ❑ PUMP 'INSTALLATION PUMP+REPAIR© <br /> REPLACEMENT❑ —• t. M .- ► '�' '.�r� v <br /> DISTANCE TO NEAREST: Septic Tank g L�` Sewer Lines Pit Privy <br /> Sewage Disposal Field_►' Cesspool/Seepage Pit Other <br /> Property Line I — <br /> Pr Domestic Well Public Domestic Well <br /> ( TYPE OF WELL <br /> INTENDED USE <br /> ❑ FN TRIAL ❑ CABLE TOOL Dia. of Well Excavation �l <br /> DOMESTIC/PRIVATE <br /> DRIL LED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑i : DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0: GRAVEL PACK i Depth of Grout Sealry 44 <br /> ❑ CATHODIC PROTECTION DIARY Type of Grout 5 S 4e� <br /> 11 DISPOSAL ❑ OTHER ` Other Information <br /> El GEOPHYSICAL ( a urface Seal In tailed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump it <br /> UMP REPLACEMENT: ❑ State Work Done ) I <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 i <br /> ordinances, state laws, and rules and regulations 5f,fhe San Joaquin Local Health District. <br /> ,', <br /> Home owner or licensed agent's signature certifles the lollowing:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any personNn 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 I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c for a Grout Inspection prior to grou in and a final inspection. <br /> Signed X Title: Date: <br /> Draw Plot Plan on Reverse Side) - <br /> FO EPARTMENT USE ONLY <br /> i. PHASE <br /> l�4" <br /> Application Accepted By, Dat <br /> Additional Comments: ® �" A <br /> P s 11 Grou nspection Ph I T Final I peif <br /> ction 41 p <br /> Inspection By <br /> Date O Inspection By Date �" j��> / -- f <br /> Fee IS Due: EI ANNUALLY ❑ PER UNIT ❑ PER SITE ❑,EACH El January 1 &Received By January 31 July 1 &Received By July 31 ' <br /> REMIT i <br /> k- BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> l DATE DATE REMITTED AMOUNT <br /> FEE All <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENAtTY <br /> OTHER <br /> :. <br /> w 1 <br /> OTHER <br /> Mailed Delivered <br /> Received by Date } Receipt No. Permit No. Is uance a e - - <br /> .APPLICANT—RETURN ALL COPIES TO:- t'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AYE.,P.O.Boz 2449 STOCKTON,'CA 45201 <br /> - <br />