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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) <br /> PUMP&WELL ' <br /> ENVIRONMENTAL IKEALTH PERMIT <br /> WATER QUALITY ► <br /> ^(COMPLETE IN TRIPLICATEy <br /> d W <br /> ApplicationisherebymadetooaqulnLo al at Istrct"tbrlipermittoconstructand/or install the work herein described.This application is <br /> made in compliance with SanCou ty Ordiinance No. 1862 and the rules and regulations of the San Joaquin Loc 1 Health District. <br /> Exact Site Address��l07 City/Town <br /> Owner's Name Phone <br /> - i <br /> Address -O City <br /> Contractor's Name oI( 41V Mg de License#,zs- 3 Business Phone 4e< –Do7 L7)2 <br /> Contractor's Address E, iZ ON Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR — ! <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 000 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> Property Line�� Private Domestic Well Public Domestic Well f <br /> INTENDED USE TYPE OF WELL J/ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of,Well Excavation <br /> DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �. <br /> ❑ IRRIGATION j ❑ GRAVEL PACK Depth of Grout Seal �D <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f� /9r �tJ <br /> ❑ DISPOSAL % ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t " Surface Seal Installed By: pe'i'ac <br /> PUMP INSTALLATION: 1 Contractor 1004CK <br /> Type of Pump Su6rn H.P. 3 <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 /> 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 <br /> is issued, I shall not'4employ 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 p ersons subject to workman's compensation laws of California." <br /> I will 11 fora ro speciion pri to grouting and a final inspect"o f <br /> Signed X Title: Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI F <br /> Application Accepted By Date� �" <br /> Additional Comments: Cy 11 <br /> ase 11 Grout Inspection ff e��y hase III Final Inspection Z /� <br /> I "1�.� � G Ins "�� ! - =� <br /> Inspection By bate,_ Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> Cy Re do <br /> FEE <br /> LESS <br /> PRORATION r _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> la - <br /> Received by Date Receipt No. Permit No. lisuancle Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 962 <br />