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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> m de in compliance with SaJoaquin County Ordinance No. 18A2 and the rules and regulations of the Sa aqu Local Heal�1 District. <br /> E t Site Address � C- City/T*n <br /> O�r1er's Name �! �-� *� Prone-I <br /> Py' ress fL°'l: t79� 1 City <br /> Contractor's Name License# -4 Business Phone l <br /> Contractor's Address f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ _ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout c� <br /> ❑ DISPOSAL ❑ OTHER Other Information y J' <br /> ❑ GEOPHYSICAL surface Seal Installed By: <br /> r; <br /> PUMP INSTALLATION: Contractor °. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <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 Sari Joaquin Local Health�DJstrict. <br /> Home owner or licensed agent's signature certifies the following:A 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 certity'that in the performance of the work for which this <br /> permit i sued, I all employ persons subject to workman's compensation laws of California." <br /> l w ca ora Inspectio riot to grouting and a final inspection. <br /> Signed X �e ITitle: ��✓ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Date w 1 <br /> I - <br /> Additional Comments: <br />' Phase 11 Grout Inspection ase III Fi ection <br /> Inspection By Date Inspection Date <br /> Fee Is Due: ❑ ANNUALLY 0-PER UNIT ❑ PER SITE -© EACH' J%1 1 & cei d nua 1 ❑ ul ? &Received By July 31 <br /> k RE <br /> RASE EXPLANATION BILLING "REMITA9 AM NTD C KED <br /> T MITTED <br /> DAE r MOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i OTHER <br /> L 76 ! � <br /> Received by Date Receipt No. Permit No. Issuance 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 /> e <br />