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Applications Will Be Processed When Submitted ProperlyCompleted. Be sureTo sign IneApplication. <br /> FOR OFFICE USE: APPUCATICl4 <br /> " <br /> (For Non-Transferable,,Revocable, Suspendable) <br /> eil, PUMP&WELL j <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLATE) <br /> IC <br /> Application is hereby made totheSan Joaquin Local Health District for apermit toconstructand/or install the work herein described.7hisappFcat'lonis r <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin LSCaI Health District. <br /> Exact Site Address <br /> pl City/Town �- <br /> iE <br /> Owner's Name r- _ a �� Phone <br /> City <br /> Address 'I =71. I <br /> Contractor's Name Inr License#� � Business Phone <br /> Contractor's Address U2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W' h SJLHD7 Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN RECONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR, <br /> REPLACEMENT❑ t �11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field r Cesspool/Seepage Pit Other <br /> Property Line{ Private Domestic Well _ _ Public Domestic Well C+ <br /> INTENDED USE TYPE OF WELL O <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing F <br /> ❑ IRRIGATION El GRAVEL PACK Depth of Grout Seal <br /> 13 CAT HODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ Surface.Seal Inst Iled fay: <br /> PUMP INSTALLATION: Contractor -Ale 6Ai <br /> Type of Pump �'y'- X� H.P: <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. j <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit I <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Calitornia." , <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this' i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r I will call for a Grout Inspectp -or t gr ing and final inspection. <br /> Signed hie: ��1' Date:. g <br /> Sid <br /> (Draw Plot Plan on Reverse e) ; <br /> :} y <br /> FORD PARTME USE ONLY <br />` PHASE I // 7 <br /> f Application Accepted By Date <br /> _ I <br /> Additional Comments: • . ' <br /> Phase 11 Grout Inspection Phas Fi Inspection <br /> Inspection By Date Inspection By Date <br /> (, Fee is Due: ❑ ANNUALLY ❑ PER UNl7 ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITd By uIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE l� <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER <br /> it Received by Date - Receipt No PWn4tN . - lss ance Date Mailed. Delivered <br /> 'a APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �-+ "=i50Y E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />