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y Applications Will Be Processed WhenSubmittedProperlyC:ompletieo. oe aureq � <br /> io�r .rtenu ,�pq.t� <br /> Foci oFF: :E usE: APPLICATION <br /> �! � <br /> (For Non-Transferable, Revocable, Sus ,ble'"), PUMP&WELL <br /> ENVIRONMENTAL HEALTH PO MIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY IL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instaRll�th;4Xr�, <br /> ,worki.1i,6�ii��k ' ' ed.This application is <br /> made in compliance with San Joaquin County Ordinan No. 1862 and he les and regulationssp-th a`it&Loc2 ealth District. <br /> Exact Site Address�/ 7 �_3 - City/TG5r5rt <br /> Owner's Name Phone /w 7�0 Z' <br /> Address City <br /> Contractor's Name �icense#tf�3 Business Phone_ <br /> Contractor' Phone <br /> s Address Emergency <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes fi No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C3OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR 0� 0I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ` Pit Privy ) <br /> Sewage Disposal Field Cesspool/Seepage Pit Other c u <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 /> ❑e <br /> IOMESTIC/PUBLIC El 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 Installed By:,_. <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H. \. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: EI-5-tate Work Done <br /> DESTRUCTION OF WELL: ,`Well'Diameter Approximate Depth <br /> Describe Material and Procedure t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County �\1 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I a!I to a Grout In cition prior t routing and a final inspe 'on. <br /> Signed X Title: Date: <br /> (Draw Plo Ian on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI l <br /> Application Accepted By Dake ' <br /> Additional Comments: <br /> Phase II Grout Inspection a Aha a 111 Final Inspection <br /> Inspection By lute Inspection By Date 7 _D7I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> CoL <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED �I°l <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> c,!39-O O Z— <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />