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Applications Will Be Processed When Submitted Properly Compleled. Be Sure To SignTheApplication. <br /> FOROjFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) # <br /> PUMP&WELL 6h <br /> w ENVIRONMENTAL HEALTH PERMIT C>. <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 thew herein described.This application is G_ i <br /> made in compliance with San Joaquin C�/unty Ordinance No. 11362 and the rules and regulations of the San Joaquin Health District. <br /> Exact Site Address �.�� Int. �o A Cdr City/Town /ss CC{{ <br /> Owner's Name A e A Phone —T 07 - s <br /> Address City r <br /> Contractor's Name i u e�S UAB + License# Business Phone G <br /> Contractor's Address mid I e Emergency Phone G "� <br /> Is Certificate of Workman's Compensation Insuran a on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION 4 <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ t 0 r— Sewer Lines rn /0T -f Pit Privy <br /> r <br /> Sewage Disposal Figld 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 Il <br /> ❑ DO ESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> , <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal \ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout LA .� <br /> ❑ <br /> ❑ OTHER Other Information I DISPOSAL , <br /> ❑ GEOPHYSICAL Surface Seal Installed By: til <br /> PUMP INSTALLATION- Contractor UM1&1e*75*,#4 <br /> Type of Pump-7n, W r'r P. y °fir I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i <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 San Joaquin Local Health District. <br /> Homeowner 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 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 will call for a Grout lnspe)lpn prior to grouting and a final inspect' �jD <br /> Signed X Title: <br /> Date: a `� <br /> (Draw Plot Plan on Reverse Side) <br /> i - <br /> FO DEPA MENT USE ONLY <br /> PHASE 4 J , �� <br /> Application Accepted BY Date <br /> Additional Comments:- <br /> -Phase <br /> omments:-Phase 11 Grout Inspection _ !"Phase Ilk Fin 'Inspection -- <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE © EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> D TE DATE REMITTED• AMOUNT <br /> FEE �-� <br /> i <br /> LESS <br /> i PRORATION <br /> i PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss6anci 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 />