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Applications Will Be Processed When Submitted Properly Completed.Be Sure a <br /> FOR o'FFICE USE: APPLICATION <br /> CD �yl4f� (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY, <br /> (COMPLETE IN TRIPLICATE) a` <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install{ihe work herein described.This application is <br /> made in compliance with San Joaquin.County OrdinanceNg- 1862 and the r les and regulati City/Toe n Joaquin Local Health District. <br /> r. <br /> Exact ��— <br /> Site Address I , <br /> Y ^. Phone ' <br /> Owner's Name ? City <br /> Address - <br /> `� ,,, License#��. Business Phone <br /> Contractor's Name +, , " <br /> .Emergency Phone S <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation Insurance on File ith SJLHD?REG I Yes' ❑ DESTRUCTION❑ y W <br /> E TYPE OF WORK (CHECK): NEW WELL[3 DEEPEN <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11OTHER C1 PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ I Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia.of Well €xcavation <br /> ❑ INDUS TRIAL Dia. of Well Casing <br /> ® DOMESTIC/PRIVATE ❑ DRILLED <br /> C3 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC. ❑. GRAVEL PACK Depth.of Grout Seal <br /> 13 IRRIGATION 4 Type of Grout <br /> 11 CATHODIC PROTECTION 11 ROTARY" <br /> ❑ DISPOSAL 1:1 OTHER Other Information <br /> ace SurfSeal Insta led By: <br /> 13 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractorf H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: 11State Work Done <br /> J9 State Work Done _..� <br /> PUMP REPAIR: Approximate Depth <br /> i <br /> DESTRUCTION.OF WELL: Well Diameter <br /> Describe Material and Procedure - <br /> I hereby certify that l have prepared this application and that the work will be doe in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y , <br /> Home owner or licensed agent's signature. <br /> ,n such mannerlas togbecomefy that in the performan <br /> subjecf to 1 o1660ian s compensace of the tiork n laws laws of California:"or which this <br /> is issued, l shall notemploy Y <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 comQen�st n laws of California." <br /> i =1 wjll call for a Grout Inspection p o to routs and nal inspection* <br /> Itle: Date: <br /> Signed <br /> (Draw Plo Ian on Reverse Side) <br /> a 1 FOR DEPARTMENT U�SE,ONLY <br /> PHASE I r. ` `T !! _ _ 5 Date Z <br /> "1 Application Accepted By , <br /> i Additional Comments: ase III Final inspection <br /> =Phase 11 Grout Inspection <br /> Date - inspection By l �` m, <br /> -} Inspection By= i r { <br /> PER UNIT ❑'PER'SITE ,❑ EACH ❑ January, &Received Sy January'31 * ' '❑ July 1 &ReceivedByJuly 31 <br /> Fee Is Due: ❑ ANNUALLY `. ❑ REMIT <br /> t t = <br /> iB1LLING _ REMITTANCE.. - $ "'AMOUNT DUE CHECKED ' <br /> `- BASE EXPLANATION DATE DATE' =REMITT _ AMOUNT <br /> FEE. <br /> 'LESS <br /> PRORATION_ <br /> PLUS <br /> PENALTY. 1`- - - •. r . <br /> OTHER <br /> OTHER <br /> t 1 V (J <br /> tPermit No. suan a Date Mailed Delivered i. <br /> Received by u Date - - Receipt No. <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV10ES <br />