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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication <br /> FOR OiFFTCE USE: APPLICATION <br /> (For Non-Translerable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) A�l ' WATERQUALITY <br /> Application is hereby made to the San Joaquin LocthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> i� made in compliance w't Sall Joaquin County Ordinance No. 1862 and the rules and regulations of the Sart Joaquin Local Health District. <br /> 1 Exact Site Address 11'2 S iZ: City/Town <br /> I Owner's N e �� . Phone <br /> Address F �} City _ <br /> Contractor's Na :I �L fC License I - Z � Business Phone q- �c5 <br /> Contractor's Address(� e A4,,,,r d-e _ Emergency Phone )Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIgN,3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION% PUMP REPAIR❑ <br /> ls— <br /> REPLACEMENTO r <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �. <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Sutre Seal Installe <br /> i' PUMP INSTALLATION: Contractor ��/ , Z <br /> Type of Pump 2ptf H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k 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 /> perm is issued, I shall employ p rsons subj Gt to workman's compensation laws of California." y <br /> I w' call for a Grout nspectio r utling and a linal.inspec• <br /> f Title Daie f � <br /> Signed X <br /> Draw Plot Plan on Re _rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � O 1 <br /> Application Accepted By` `� Date a� <br /> Additional Comments: <br /> Phase II Grout Inspection 1 III Final inspection <br /> inspection By Date Inspection By Dated l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLINGREMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> * OTHER <br /> OTHER <br /> aS40 <br /> Received by -Date Receipt No, Permit No. I suance qate I Mailed Delivered <br /> �' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box.2,009 STOCKTON,CA 96201 <br />