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Apoi a .. <br /> Applications Will Be Processed When Submitted` roper y omp e <br /> �. APPLICATION r <br /> FI0'R 00TOC E USE: <br /> (For Non-Transferable, Revocable,Suspendable) <br /> _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance a agfi ounty Ordinanc 1862 and the rules and regulations of the S quin Loc IT h pis�tr�Ic ` <br /> Exact Site Address — City/Town <br /> 4-r <br /> Phone <br /> Owner's Name <br /> Address 0 S -r yre ## City <br /> L�cense <br /> Contractor's Nam Business Phone <br /> Phone <br /> Contractor's Ad cess -- rgency I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> � <br /> TYPE OF WORK (CHECK): NEW WELL. RECONDITION 11DESTRUCTION❑ <br /> LO11 r <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> 4 REPLACEMENT❑ I}Y <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines J© C? I _ Pit Privy <br /> I Sewage Disposal Field_ D 0 / Cesspool/Seepage Pit �Other '� <br /> Property Line — Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> l ❑ CABLE TOOL Dia. of Well Excavation <br /> ,❑,-,,�� <br /> INDUSTRIAL <br /> ��+'DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC l ❑ DRIVEN Gauge of Casing Y <br /> f <br /> 11 IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> I ryI�,�— <br /> ❑ CATHODIC PROTECTION 9 1iL)l ARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: S <br /> ;I <br /> s PUMP INSTALLATION: Contractor <br /> lType of Pump. H.P. <br /> f PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> #, DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> f I hereby certify that L 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 /> I is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Californiaisllowing:"I certify that in the performance of the work forwhich th <br /> Contractor's hiring or sub-contracting signature certifies the fois «r <br /> permit is issued, I shall emplo s subject to workman's compensation laws of California." <br /> Ill calf for a Grout Inspe or to routing and a final inspection. <br /> Si ne <br /> l Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY 1 <br /> PHASE I Date <br /> Application Accepted By }(_ -2 �Z <br /> Additional Comments=-(_ <br /> ha a II Grout Inspection Phase Ill Final Inspection <br /> Date Date <br /> Inspection By , Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEB^yl Joly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> a <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fSSS 72 (ncl 0_7? <br /> Received by <br /> 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 95 <br />