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pplicationsWill Be Processed When Submitted Properly Completed. B e"S T <br /> ��� �~St plication, <br /> FOR�� ICE usE: APPLICATIQ �' �i \y�I y/ <br /> (For Non-Transferable, Revoc , S ie I�a4e) Q <br /> PUMP&WELLp� <br /> ENVIRONMENTAL HEA PE T $ 19 1 '1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �� <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or tt1t5111.t�l+ewo � �`ndescribed.This application is <br /> made in compliance with San Joaquin County Ordjnance No. 1862 and the rules and remibs gs�ajfsitaQuin Local Health District. <br /> Exact Site Address � _ l own <br /> Owner's <br /> w <br /> Owner's Name Phone 7` �� �� r <br /> Address O _ City <br /> Contractor's Name �� f License#�G�3 7 Business Phone 4 Z <br /> Contractor's Address '3o Emergency Phone �� .J� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD� Yes_ No OC1� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <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 ,I <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION _ - ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ❑ ROTARY Y <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump • H.P. .Sr <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 .1 <br /> a <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 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 wit all f r a Grou Inspection prior to grouting and a final in ection. <br /> Signed X d/ _ . __ _ Tiile: <br /> Date:. '�C} <br /> (Draw Plot Plan on Rever a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By —""� 1� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha III Final Inspection Z <br /> Inspection By Date Inspection ByA& ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �'� O <br /> LESS ill <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l4 /--M—,,Ied�Received by Date Receipt No. permit No. Iss ante D to Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 , <br />