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Applications Will Be Processed When Ssrlti�iedfrroperly Completed. Be Sure To Sign The Application. 9� <br /> FOR OFFICe-USE: / APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 7 a PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j < <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 thework herein described.This application isw <br /> made in compliance with San Joaquin county Ordinance No..:1862 and the:rules and regulations of the San Joaquin Local Heal h District. <br /> Exact Site Address rc• D City/Town =_2 d <br /> Owner's Name Phone <br /> Ad d ress /�� City <br /> Contractor's Name ~ `" License# r2! ?,Q Y_/:3 Business Phone _ r< <br /> Contractor's Addressc� Emergency Phone J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No } <br /> TYPE OF WORK (CHECK): NEW WELL U� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ p h <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ d <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank q4 1t_ Sewer Lines Pit Privy <br /> Sewage Disposal Field 9E 01 — Cesspool/Seepage Pit Other <br /> i <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 "QVC, <br /> ❑ DOMESTIC/PUBLIC y❑ DRIVEN Gauge of Casing A"`o�ad-� <br /> ❑ IRRIGATION yx GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information CA 6WX94 <br /> 13 GEOPHYSICAL. Surface Seal Installed By: _ G�tC er� -� <br />'A PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Q <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 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 /> Homeowner 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 lorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit call for a Grout Insp ion prior to outing and a final inspection. <br /> Signed X Title: <br /> Date: ; <br /> ( raw Plot Plan on Revers Side) ,u A47 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE p <br /> Application Accepted By ,► �' . Date <br /> Additional Comments: <br /> Ph e I Grout Inspection // P ase III Final Inspection <br /> Inspection By f Date_ Zai - __ Inspection By N, Date - z% s� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to 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 /> A' <br />