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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> tF.OR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMPWELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Applicat;pn is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in Compliance with San Joaquin County/Ordinance CNof1862 and the" rules and regulations_ t e San Joaquin Local Health District. <br /> Exact Site Address Pa PI C y own <br /> Owner's Name ' IPhone 72)ZP k r^• City— /��sf D <br /> Address <br /> Contractor's Name License# A 74;5Business Phone <br /> Contractor's Address 4140deSA9 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1/ No <br /> TYPE OF WORK (CHECK): NEW WELLIV DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ v <br /> DISTANCE TO NEAREST: Septic Tank A011P Sewer Lines Pit Privy <br /> Sewage Disposal Field 11bnc_ Cesspool/Seepage Pit Other t �� <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL u <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC �❑,, PRIVEN Gauge of Casing -0 C. C'l <br /> ❑ IRRIGATION LEYGRAVEL PACK Depth of Grout Seal �e <br /> i <br /> ❑ CATHODIC PROTECTION WROTARY Type of Grout 7 <br /> ❑ DISPOSAL ❑ OTHER Other Information _!1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .1 G1� <br /> PUMP INSTALLATION: Contractor <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 /> I hereby certify that I have prepared this application and that the work a San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Lo l� <br /> Home owner od licensed agent's signature certifies the following:"I certify a performance of the rk for which this permit <br /> is issued, I shall not employ any person in such manner as to become su t to wlo'rk n nsation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify th l [�h jhdfo Fence of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," 4S;. <br /> I w'1] C li for a Grout Ins tion prior to grouting and a fina/ins ection. A IN LOCAL%EW" <br /> �QSigned X ut Ti#ItiN��L HEALZN QIV Date: /Af <br /> ( raw Plot Plan on Reverse de)' <br /> FOR EPARTME T USE ONLY <br /> PHASE I Q` p.� <br /> Application Accepted By Date U �� 4`� <br /> Additional Comments: <br /> Phase II Grout Inspection I Final Inspection <br /> Inspection By Date InspectioVeceived <br /> Date <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT PER SITE 13 EACH ❑ January 1 By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER .t <br /> s <br /> OTHER - -4 <br /> Received bate Receipt No. Permit No. Is uance Date Mailed Delivered <br /> APPLI ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />