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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: �y 'PPLICATION <br /> (For n-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> 400-' ENVIRONMENTAL HEALTH PERMIT <br /> e {COMPLETE IN TRIPLICATE} WATER QUALITY <br /> ' Applicationishe_rebymadetotheSanJodgUinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> `. made in compliance with an Joaquin C]ounty O dinanc o. 1262 and the rules and egulations of the San Joaquin Local Health District, <br /> Exact Site Address 'J'dJl 3` /`€ ' / '� � City/Town <br /> Owner's Name . .t;a�.; ,' .ski- "r``•fir Phone <br /> Address tL C,, r'dj n tiG - '. _City y r - 4 4­ <br /> Contractor's Name 'P'"�wt,Jf ;P •yn " .✓ _ License# Business Phone t _ <br /> Contractor's Address'- ` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With.9JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ vow <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP F(EPAIR <br /> t REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL U <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL ' Surface Seal Installed By: to <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i ,rd? ' T H.P. �l <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done _ fi r " <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure G <br /> 1 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." C <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 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X �._, ?,_, � 'f �r .s�a�. : j,sTitle: h — Date: <br /> (Draw Plof,Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By %Z✓"` � { r Date <br /> f <br /> Additional Comments: <br /> i Phase it Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> /DA DATE REMITTED AMOUNT <br /> FEE r <br /> LESS f �i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _ OTHER <br /> Received by ,. Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> 5 <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYiCES - 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOCKTON,CA 85201 <br />