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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> FOR OFFICE USE: i APPLICATION r <br /> 3 / / <br /> x <br /> h /a (For Non-Transferable, Revocable,Suspendable) J PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 7.3 e _5� ATER QUALITY n o? F r�S 2-0 —D k <br /> Application is hereby made to the SanJoaquin Local Health Distri fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882the rules regula ions of the San Joaquin Local Health District. <br /> Exact Site Address i a City/Town <br /> Owner's'Name " / Phone <br /> Address City <br /> Contractor's Name 4Ag License# Y,I ` Business'Phone <br /> Contractor's Address Emergency Phone " y <br /> ;. <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL-0 DEEPEN 1771' _ RECONDITION❑ a DESTRUCTION❑ y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -_' :PUMP INSTALLATION ❑ PUMP REPAIR IS <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field _ Cesspool/Seepage Pit Other <br /> 1, <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 iI ❑ DRILLED Dia. of Well Casing t <br /> ❑ DOMESTIC/PUBLIC il� ❑ DRIVEN Gauge of Casing VV, <br /> I IRRIGATION © GRAVEL PACK Depth of Grout Seal O i <br /> ❑ CATHODIC PROTECTION ; ❑ ROTARY Type of Grout l <br /> ❑ DISPOSAL ❑ OTHERWOther Information <br /> 11GEOPHYSICAL _ Surface Seal Installed B I <br /> PUMP INSTALLATION: Contractor w I <br /> Type of Pump K H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I� State Work Done <br /> DESTRUCTION OF WELL: I" Well Diameter F <br /> Approximate DepthIn <br /> 41 Describe Material and Proce <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 /> 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 forwhich this <br /> t permit is issued, I shall"employ persons subject to workman's compensation laws of California." <br /> x <br /> I Vol, call for a Grout Inspectigi pr r routin d a final inspection. <br /> Signed _ Date: ad <br /> 'y (Draw Plot PI on Reverse Side) <br /> j. <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By �`""� Date �! 'Gta+C . <br /> Additional Comments: <br /> Phase II`131 rout Inspectionhose III Final Ins ection <br /> Inspection By �644 ,Date Inspection By � � Date <br /> Fee Is Due: 11 ANNUALLY {I❑ PER UNIT El PER SITE ❑ EACH ❑ January i&Received By January 31 ❑ July 7 &Received By July 37 <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i. FEE <br /> LESS A <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -- - _ <br /> OTHER 7. - <br /> 46 <br /> Received by +-•pate�� - Receipi No.� Permit No. -_ Is uance D to Mailed -- Delivered . . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.8or 2009 STOCKTON,CA 95201 ' <br />