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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 Lf ^ —7,5- C)l<- <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY d <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin_Count y rdinance No. 186and th rules-and regulations of the San Joaquin Local Health District. <br /> � � " �% 6c� , tC,Cs City/Town <br /> Exact Site Address _� – ; - <br /> •. <br /> w` . Phone-S -3 Y <br /> Owner's Name _. <br /> Address City r— <br /> ti License# .3 `2 -. Business Phone _ ' <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address <br /> ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes <br /> L..� No <br /> TYPE OF-WORK (CHECK) NEW WELL'❑ .. DEEPEN ❑ `RECONDITION❑ DESTRUCTION❑ ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IZ - PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> 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 /> ❑ IND STRIAL 11CABLE TOOL Dia- of Well Excavation <br /> ll1 <br /> ,�sDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> � <br /> 13DOMESTIC/PUBLIC ❑1 DRIVEN Gauge of Casing %3 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> f <br /> ❑ DISPOSAL s ❑ OTHER Other Information <br /> 11 GEOPHYSICAL r Suurrffacc Seal Installed By: , <br /> PUMP INSTALLATION:: Contractor ` <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑. State Work Done 4 <br /> f.._.� <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter I <br /> T 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit j <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 t ,r a Grout Inspection prior to grouting and-a final inspection. - <br /> Tltle: � <br /> (Draw � Date: T <br /> Signed <br /> Plot Plan on R, erse Side) <br /> - FOR DEPARTMENT U ONLY j <br /> ' PHASE f � .Date <br /> Application Accepted By <br /> r Additional Comments: Kase I Final Inspection <br /> Inspection.Byill-Grout <br /> PhaseInspection <br /> Date Inspection By Date <br /> UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 F] July 1 &ReceiveRd By my 31 <br /> Fee IS Due: [I ANNUALLY El PER <br /> BILLING REMITTANCE $. AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE 'REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS J <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPL <br /> � APPLICAA <br /> NT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.BoK 2009 STOCKTON,CA 95201 <br />