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FOR OFFICE USE: applicationWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.' <br /> � P <br /> Is <br /> APPLICATION <br /> " i 5 (For Non-Transferable, Revocable; Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 uin CountyCrdigaWe No. i 62 and the rules and regulations of the San Joaquin Local Health D' trict. <br /> Exact Site Address gal ��'' <br /> City/Town <br /> Owner's Name <br /> Address Phones <br /> Contractor's Name City" <br /> Contractor's Address License# f Business P ne <br /> �� .fit. 7 Emergency Phone >: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No Lam~ <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN 13 WELL CHLORINATION 13I RECONDITION❑ DESTRUCTION❑ <br /> REPLACEMENT❑ S C3WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONPUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank .. �• <br /> Sewer Lines Pit Privy <br /> Sewalge Disposal Field Cesspool/Seepage Pit <br /> INTENDED USE Public Domestic Well <br /> Property Line Private Domestic Well Other <br /> ❑ IN�].CJSTRIAL TYPE OF WELL <br /> �� I ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> Cl DOMESTIC/PUBLIC Dia, of Well Casing <br /> ISI ❑ DRIVEN - Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> ❑ CATHODIC PROTECTION ❑ ROTARY �� - Depth of Grout Seal <br /> ❑ DISPOSAL ❑ OTHER a` _Type of Grout <br /> ❑ GEOPHYSICAL Other Information <br /> PUMP INSTALLATION: 4 r -z§urface Seal Installed By: <br /> Contractor <br /> ?i J Type of Pump ' <br /> PUMP REPLACEMENT: ❑ State Work Donee H. <br /> PUMP REPAIR: <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL , er <br /> : (a <br /> Well Diameter <br /> �� � �' Approximate Depth U <br /> Desc ibe 4aterial and Procedure <br /> I hereby certify that I have prepared this a `'�•G{' <br /> pp(cation and that the work will be,b6ne in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> CA <br /> Homeowner or licensed aglent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 shatl not em to an <br /> employ y person in such manner as to become subject to workman's compensation laws of California." d <br /> Contractor's hiring orsub-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 /> ill cal r a GroutJnspe`ctionrlo0Ir to gr ting and a nal inspection.. <br /> Signed I <br /> Title: rxr t*,r- Date <br /> {Draw Plat Plan on Reverse Side) <br /> I�p FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> l <br /> Additional Comments: iM. Date <br /> Phase If Grout inspection <br /> Inspection 8y ,bP s It Final I action ` <br /> Date Inspection By t r/tate �it . <br /> FEE IS Due; ❑ ANNUALLY ❑ PER UNIT PER SITE <br /> ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> IP <br /> BASE M EXPLANATION BILLING REMITTANCE $ REMIT <br /> A DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r _ _ <br /> OTHER <br /> 5`3 �7 <br /> Received by Oat. c1 <br /> I Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMIT/SEAVICES suance Date Mailed -Delivered- -- <br /> 1609 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />