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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> --f5mce USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .,WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance Joa uin County O i ons of the San <br /> wit San ance No 1862 and the rules arid regulations <br /> Jo uinL CO Health District. <br /> Exact Site Address City/Town ��Gf! <br /> Owner's Name ' Phone I <br /> Address "�1 �� City <br /> Contractor's Name icense#.w <br /> Business-Phone o� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation lnisu5ance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): t " NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION El— PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> t <br /> DISTANCE TO NEAREST: Septic Tank _4S Sewer Lines !�Q.` Pit Privy <br /> Sewage Disposal F' Id Cesspool/Seepage Pit Other <br /> saw Property Line.Private'Domestic-Well'`"—�- Public'Domestic WeIG !` � r <br /> 'INTENDED USE_ E TYPE OF WELL $$ ► ' 1 <br /> t, `I n 114.; - rY Z1.2--1 f <br /> ❑,INDUSTRIAL *' 'c+ �' ❑ CABLE TOOLS �`v # Dia. Of Welt Excavatioh' <br /> ,S,.,� � t l <br /> ❑ DOME h ( uQ<DF31LI EI3iti y* tl7ia. of Well Casirsg � e r - �- <br /> i�-. .� T.�..� �. �..s,"...5 �fir'e - + = t. �:.• �' <br /> ❑ DOMESTIC/PUBLIC *� <br /> 13. <br /> DRIVEN ' ti Gauge of Cas ng c .�6. ` <br /> ❑'IRRIGATION °�. L"* � ©`�GFIA`1/EL=PACK ! 4 Depth _f Grout Seal "�' ` r#` <br /> "U-CATHODIC PROTECTION _'L_®ROTARY Type of Grout <br /> ' ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface S In tall§d Byl <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done _. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Material and Procedure <br /> I hereby certify that I havepreparedthis 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 /> I 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 compensation laws of California." <br /> I 1 'a G s ion prior to grouting and a final inspection. <br /> Signed X Title: ' - Date: <br /> (Draw Plot Plan on Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ' ! Ar—fl.(k— t7ate� �` <br /> Additional Comments: ' <br /> Phase II Grout Inspection III Final Inspection <br /> spection-B ,Date Inspection By Date 40 <br /> .1 <br /> Fee Is Due: ❑ ANNUAL ❑ PER UNIT ❑ PER SITE AD EACH ❑ January I &Received By January 31 El July I &Received By July 31 <br /> REMIT <br /> BASE" EXPLANATION BILLING REMITTANCE _ $ AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> 0 <br /> FEE <br /> LESS <br /> PRORATION f ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y 1 Date p Re eiM No. Permit No. Is uance Date: Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />