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pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE; APPLICATION <br /> (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 Joa in Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with Sa Joaquin CC6n'0 ance No. 2 a d the rules and regulations of the Sa a pin Local Health District, <br /> Exact Site Address 4 0 <br /> c City/Town <br /> Owner's Name Phone o <br /> Address I qID City <br /> Contractor's Name License# �/ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ce <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTI <br /> WELL CHLORINATION 13 WELL ABANDONMENT El OTHER E] PUMP INSTALLATIO PUMP REPAIR❑ d <br /> REPLACEMENT❑ fI <br /> 3 ,- a <br /> DISTANCE TO NEAREST: `Septic Tank _ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage'Pit' Other f <br /> " .. ,Property Line `"`9 Private;Domestic Well F �,. Public Domestic Weil <br /> INTENDED USE TYPE'OF-WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ _ Dia. of Well Excavation u <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED '`, Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN ;Y Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal A <br /> ❑ CATHODIC PROTECTION 1:1 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER : <br /> Other Information <br /> ❑ GEOPHYSICAL '"` Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor c <br /> Type of Pump, 'Hy <br /> rP 1 <br /> PUMP REPLACEMENT: El State Work o e 4 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter', '� <br /> ' .-. _ � Approximate Depth <br /> 'I ,Describe;Material-and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinan,'c6s„ state'laws, and rules and regulations of the San Joaquin Local Health District. <br /> .+ <br /> Homeowner or licensed ag nt�s-signature certifies the following:"I certifythat in the performance of the work for which this permit i <br /> is issued, I shall not employ anso <br /> y-pern.vin*such,manner-as to beco_m' a sd`1 ject 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 7a (grout Inspection p�a�to outing x da final inspectio / <br /> Signed X Title: .C� a4f-�I' �` rl ( {)'• <br /> �JE4 Date: <br /> (Draw,Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> Application Accepted By _ /_ Date y� <br /> 6;.i � ! L <br /> Additional Comments: �¢� 4�F,` Q'/l/ T�.�jc�lr�ia �� <br /> Phase .Grout Inspection <br /> Phase III Final inspection <br /> € Inspection By ItDate Inspection By D to Z— z— 71 <br /> Fee Is Due: ❑_ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 & d By July 31 <br /> BILLING REMITTANCE REMIT <br /> ,,. BASE -EXPLANATI N $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS — } <br /> PRORATION <br /> t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by" ate Receipt No. Permit No. Issu nce Da a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952131 <br />