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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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County dinance No. 862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address - City/Town <br /> Owner's Name%� witty �'�.c� ��, Phone 2 G P— D 6 ),. <br /> Address <br /> City <br /> Contractor's Name License#�_.�_ 73 Business PhoneContractor's Address /3 (-D }�. �.t_e �_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ S� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Ca-0/ —2) <br /> REPLACEMENT❑. f <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 i Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN .Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Infbrmation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1� <br /> '1 <br /> PUMP INSTALLATION: ContractorD �I <br /> y Type of Pump= � —� H.P. / �t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: EYState Work Done JFA4=44 If <br /> DESTRUCTION OF WELL: r Well Diameter I I I <br /> s Approximate Depth <br /> " Describe Material and Procedure v <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 /> 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 wi all f r a GrQat ection prior o grouting and a final inspection. <br /> Signed X <br /> itle: 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' ha a III Final In_speectii n <br /> Inspection By Date Inspection By G"Tjate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEGd4 <br /> LESS Jn <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �s 5 s l7 � <br /> Received by Date Receipt No. Permit ND. I suanc 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 />