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Applications Will Be Processed When Submitted Properly Completed. Be.Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ' <br /> II (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> .I r <br /> ENVIRONMENTAL HEALTH-PERMIT <br />" (COMPLETE IN TRIPLICATE) WATER QUALITY, <br /> Application is hereby made to the San Joaquin Local Health District.fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin CCoounty.Ordinance No. 1862 and the rules and regulations of the San�Joa[{ intLocal Health District. <br /> Exact Site Address ! � 4C y City/Town <br /> Owners Name ''. T ..e t, , . t:Y ., �. <br /> Phone t � <br /> Address . ' } <br /> City <br /> Contractor's Name ' { License#�l Bust s Phone <br /> Contractor's Address Q' t Emergency Phone - � 4 <br /> Is Certificate of Workman's Compensation Insurance on.File With SJLHD? Yes A-- No <br /> TYPE OF WORK (CHECK): NEIN 1NELL 13DEEPEN ❑" RECONDITION❑' "DESTRUCTION❑ - C + <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION B'PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> ik <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,, 11 D STRIAL ❑.CABLE TOOL Dia. of Well Excavation <br /> 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC it ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL Ij ❑ OTHER Other Information e <br /> ❑ GEOPHYSICAL I Sur a Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor 40 <br /> Type of Pump P pG <br /> PUMP REPLACEMENT: " ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done .J <br /> DESTRUCTION,OF WELL: Well Diameter Approximate Depth # <br /> t <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:6ntracting 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 compensation laws of California." <br /> I call a roul Inspec'o r' r grouting an a final inspection. t <br /> r <br /> Signed Title: Date <br /> (Draw Plot Plan on R v�Side) <br /> II ' FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Dale � � <br /> Additional Comments: t <br /> hose 11 Grout Inspection ; �Phas III Final Inspection <br /> Inspection By -..Date Inspection By Date <br /> � - f <br /> Fee Is:Due: ❑ ANNUALLY ❑ ❑ ❑ <br /> PER UNIT PER SITE' EACH ❑ January 9 &Received nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE ' '' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE F <br /> LESS <br /> PRORATION " <br /> PLUS . <br /> PENALTY '! <br /> OTHER :. <br /> OTHER <br /> A. 1,316S . <br /> - Received by Date ,k Receipt No. Permit'No, - Iss nce to Mailed d Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 g <br /> n <br />