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pplicationsWillBe Processed When Submitted Properly Completed. Be Sure To Sig The he Application. - <br /> FOR OFFICE USE: APPLICATION <br /> ' (For Non-Transferable, Revocable, Suspendable)A. <br /> I <br /> t <br /> ENVIRONMENTAL.HEALTH PERMIT PUMP&WELL <br /> x' (COMPLETE IN TRIPLICATE) r WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wi h San Joaquin County Ordinance No. 1862 and therules a regulations of the San Joaquin Local Health District. <br /> Exact Site Address ve— 1199 4,-* e�t/ ity/Town <br /> Owner's Name r <br /> Address 4 <br /> Phone <br /> City <br /> Contractor's Name ,. License#/-as7� Business Phone BZJ <br /> F Contractor's Address - Emergency Phone �� l <br /> Is Certificate of Workman's Compensation Insurance o File ith SH D? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ <br /> PUMP REPAIR❑ } ' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> p Sewer Lines Pit Privy <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other <br /> INTENDED <br /> t Property Line Private Domestic Well Public Domestic Well <br /> INTENpED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ElDOMESTIC/PRIVATE E] DRILLED Dia, of Well Excavation <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> F-1IRRIGATION 11GRAVEL PACK: Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION El ROTARY <br /> ❑ DISPOSALType of Grout <br /> ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL Surface Seal.Installed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump m H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - ]' <br /> PUMP REPAIR: ❑ State Work Done 3 <br /> DESTRUCTION OF WELL: Well Diameter + ' <br /> ,. Approximate Depthelk <br /> OD ; <br /> Describe Matejpl and Procedure <br /> 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 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 %l call for a�Grout Inspection p ' r to grouting arid a final inspection. - <br /> Signed X A!OJ ;+�; p <br /> Title: _d444fa2(e Date: <br /> (Draw Plot_Plan on Reverse Side) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ? <br /> Application Accepted By - Date <br /> Additional Comments: <br /> Phase II Grout Inspection I Final inspection <br /> Inspection By Date Inspection Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 g,Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT. <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE 0.00 AMOUNT <br /> LESS a <br /> PRORATION <br /> PLUS <br /> 3 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ecei by Date Receipt No. _Permit N6. .• ,Issuance Date Mailed <br /> APF'}-CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH•PERMIT/SERVFCES Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ! <br />