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Applications Will Be,Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Cont ° (Far Non-Transferable, Revocable Suspendable) / <br /> PUMP&WI=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862 and the rules and regulations of the San JOuin oc Health District. <br /> Exact Site Address �i/19 <br /> 'OF <br /> Exact City/Town - y�s7ti <br /> Owner's Name /�� ha 1 <br /> � -I4 Phone <br /> Address - / City <br /> Contractor's Name <br /> License# «'3'72-S- Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes�� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION[] -� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR i <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 In ed By: I <br /> t <br /> PUMP INSTALLATION: Contractor �� ! Cc <br /> ,, f <br /> Type of Pump X ! H.P, / \_ <br /> PUMP REPLACEMENT: J9 State Work Done ., 0,-O, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diamete5- 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 /> ,r <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 ill call for a Grout Inspection prior outing and a final inspection. r <br /> Signed Title: /&J Date: <br /> IF (Draw Plof Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By i Is `-�"'���^'l � Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection I <br /> Inspection By Date Inspection By Date i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMfTTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DATE DATE REMITTED DUE CHECKED <br /> J `F ) AMOUNT <br /> FEE 7 G 1 s^--� <br /> LESS r <br /> PRORATION ` <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> nTHER <br /> 1 4 L <br /> carved by Date ,I Receipt No. Permit No. Issuance Date 7Trrgd Delivered <br /> kPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />