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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-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sap Joagyin Local Health District. ' <br /> Exact Site Address °'� `� `= I ' ' 1 City/Town Q_ <br /> Owner's N me .I,� . c P:J $"�. «. $ Phone <br /> Address City 1=, <br /> Contractor's Name(' �` ` ' '� ', �' t � � �5 License S'3 Business Phone 3 `7 <br /> Contractor's Address;" 4 Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yeses- No 1 <br /> TYPE OF WORK (CHECK): NEW WELL&' DEEPEN El RECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / Sewer.Lines Pit Privy rrfr <br /> Sewage Disposal Field Cesspool/Seepage Pit Other v� <br /> Property Line Private Domestic Well , Public Domestic Well A' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ <br /> ❑ DRILLED Dia. of Well Casing <br /> - <br /> 'DOMESTIC/PRIVATE 9 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing • <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal '" <br /> ❑ CATHODIC PROTECTION 99--PiOTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorL,_ <br /> Type of Pump' `zs= .'• H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done v � <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: WeII.Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> 1 hereby•certify that I have prepared this application and that thenwork 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 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 forwhich 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 /> Signed X Title: C=3' ti ,.,.� �-��., _ Date: <br /> (Draw Plot Plan on Reverse Side) I <br /> FOR 61iPARTMENT USE!ONLY <br /> PHASE <br /> ` F f rCr r Date <br /> Application Accepted By y} f <br /> Additional Comments:- <br /> Phase <br /> omments:Phase 11 Grout Inspection - Phase Iii Final Inspection <br /> Inspection By Date Inspection By Date---- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE �E] EACH` ❑4January 1&Received By January 31 ❑ July 1 &Received By July 3) <br /> REMIT <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 /> OTHEE,R. <br /> � '14 Fd � a Y7­�-_3 17 ? tl:� S/,F y - <br /> Received by I Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />