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Applications Will Be Processed When Submitted Properly Cam III dte r4 o0!Igp�Thl licatian._ Y <br /> -FOR OFFICE USE:S APPL,ICATI �"'� <br /> Kyf <br /> (For Non-Transferable, Revocab spendable)-i 19�a <br /> ENVIRONMENTAL HEAL PER;ilIFPP PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �DQ��I,tN�TTLR GSL <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construcl%r�roNQ",�rk herein described.This application is <br /> made in compliance wl oj�qui ov_nt1Ordinance 1862 and the rules and re ula I of the San a uln Loga�i-HHealt District. <br /> Exact Site Address /_ /p��►'+? � E g City/Town ��G " <br /> Owner's Name �� � Phone 1��4 <br /> Address _ _� + City <br /> Contractor's Name I'��11t il°M St 1 3 e,l <br /> License# Business Phon <br /> Contractor's Address Emergency PhonQ <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes :/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ t);PUMP71NSTALLATION R;::� PUMP REPAIR❑ <br /> REPLACEMENT❑ ti <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 /> DUSTRIAL d CABLE TOOL Dia. of Well Excavation 3 <br />–,,,� DOMESTIC/PRIVATE" y ❑ DRILLED' Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal (h <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T 1 C <br /> ype of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SurfpSeal Installed talled y: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump- H.—P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> Home owner 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 g arsub-contracting signature certifies the following:"I ify that in the performance of the work forwhich this <br /> per I d I sh II emp sons subject to workman's compe Ion laws of California." <br /> I ill r Inspect In p or to groutinnd'a final ins en. a�A <br /> Signed X Title: Date: r <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPAR ENT USE ONLY <br /> PHASEI <br /> Application Accepted By i <br /> Date <br /> Additional Comments: ' y' ' <br /> Phase II Gro t Inspection Pf�aLIFinal inspection �4 <br /> Inspection By Date Inspection y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July`311 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS Td <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER R_ <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 } <br />