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Applications Will fie Processed WhenSubmitted Properly Completed. BeSureToSign TneApprrcanon. f <br /> FOR OFFICE USE: �J APPLICATION <br /> �ryc l0 (For Non-Transferable, Revocable, Suspendable) <br /> �"""'� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Ordinance No. 186,2E and the rules and regulations of the San Joaquin loc I Health District. <br /> Exact Site Address .2U `3 City/Town <br /> Owner's Named / Phone <br /> Address v City c <br /> Contractor's Name 0 License# /9� Business Phone <br /> Contractor's Addres Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on F!! With SJLHD? Yes _ No _ 1 <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPE ❑ RECONDITION❑ DESTRUCTION❑ l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <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 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 Information <br /> ❑ GEOPHYSICAL Surface Seal Install d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P: / <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done CA 4j! to 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:"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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will gall for a Grout Inspection pr' 1 r uti nd inal inspection. f <br /> Signed X e: Date: /4-7/4p_7 ` <br /> IV (Draw Plat an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY PHASE I � y`�+� �� �._a� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase lil Fi I Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January Y &Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE' $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No I Issuance lbate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />