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Applications 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 /> PUMP&WELL / <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TIIPLICATE) WATER QUALITY w <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.phis application is <br /> made in compliance with San Joaquin County Ordina ce o, 1882 and the rules nd regulations of the San Joaquin Local Hea h District. , <br /> Exact Site Address flo/J���//`�� ! /� ._/ �GY)2'�/ City/Town <br /> Owner's Name G�fLGZ / '/. }[_ _ L[d![�� Lcl�La(✓1P�'_Bf,one 7 T <br /> Address City <br /> Contractor's Name License# Business Phone -- <br /> � S—�� I <br /> Contractor's Address � EmergencyPhone � ? <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes N No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ C � <br /> DISTANCE TO NEAREST: Septic Tank _ .5D Sewer Lines Pit Privy <br /> Sewage Disposal Field — _�� Cesspool/Seepage Pit Other <br /> Property Line &2 " .. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation / <br /> XDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing '�f'!lG <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal f2 <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.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: ❑ State Work Done _ r.1 <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Ins ection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw PI Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted y Date ��� <br /> Additional Commen <br /> i <br /> rout Inspection t se III Final Inspection / <br /> Inspection B f se I GDate Inspection Date <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 r <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cei d 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 9520 <br />