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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> Foci OFFICE USE: APPLICATION <br /> i' (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made,to theSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Jo�aguin County.Ordinance No. 1862 and the rules and regulations of the San J qu'n Local Health District. <br /> Exact Site Address +� *� �r �✓ City/Town <br /> Owner's Name r _ Phone <br /> Address City <br /> Contractor's Name License#..2 Mf BusirWss Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONIr <br /> ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> ig£ ❑ <br /> REPLACEMENT <br /> _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /moo Pit Privy- -x 6 <br /> Sewage Disposal Field—42) Cesspool/Sepage Pit `': '-Other 3 <br /> b' ' • 'Property Line- Private Domestic Well Public Domestic Well ' <br /> INTENDED USE Y ` -"` "PPE-OF WELL <br /> ❑ IN USTRIAL "`_ ®/CABLE TOOL `'Dia. of WeI1 Excavation <br /> P!`bOMESTIC/PFIIVATE_ ❑ DRILLED Dia. of Weil Casing 4 <br /> ❑.DOMESTIC/PUBLIC 1 ❑ DRIVEN T Gauge of Casingt -.'. T <br /> *IRRIGATION �'� - ❑ GRAVEL PACK Depth-of Grout seal <br /> t " - 5 - <br /> ❑ CATHODIC PROTECTION.'` ❑ ROT,ARY Type of Grout <br /> ; <br /> ❑ DISPOSAL DYOTHER Other Information—! � <br /> ❑ GEOPHYSICAL. Surface Seahlnstalled By: ' <br /> PUMP INSTALLATION: _ _ _Contractor <br /> ­41 1_ H.P. <br /> - Type of Pump <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: W <br /> . ❑ Stat ork Done'" <br /> DESTRUCTION-OF WELL: I Well Diamete --.rq _ Approximate Depth <br /> Desscriibbe.Material'and Procedures <br /> ,s { h&eby certify that I have prepared this application and that the work will be done in accordance witli San Joaquin County <br /> ordinances,.state-laws, anrd rules and regulations of the San Joaquin Local Health,District. k } <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which-thi P rmit <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." r <br /> I will II for a Grout ins ctlo prior to grouting and a final inspection. F <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ,) , ti� ,Y ; { "FOR DEPARTMENT USE ONLY _ <br /> PHASE I_ •f{. J t — <br /> Application Accepted By Q Date <br /> t <br /> Additional Comments: <br /> (Phase II rout Inspec.'o ! ` Phase III Final Inspection t <br /> Ih Inspection y Inspection y Date <br /> $ ok . <br /> �. <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 1:1 PER SITE ❑ EACH � ❑ January 1 & eceived By January 31` ❑ July 1 8 Recei d By July 31 <br /> - 4 REMIT <br /> BASE EXPLANATION <br /> BILLING irrEMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F s <br /> FEE <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER µ <br /> F <br /> OTHER <br /> x _-_ vs 1 <br /> M^Received by Date - Receipt No.` Permit No. .h Iss ante Dae Mailed De:ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009- STOCKTON;CA 95201 <br />