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Applications Will Be Processed When Submitted Properly Completed BeSure rooign I"t:nF t <br /> FOR OFFICE use: APPLICATION l <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ' t <br /> "= <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Applicakion�isherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstaHthework.hereindescribed.7hisapplicativnis <br /> made in compliance with Sari Joaq in County Ordinance N 186 a ,d.the rules and regu) iv sof ttt+s an Joa uin Lvca�Healt �ict� <br /> Exact Site Add'resskk5 <br /> 1e Phone' <br /> Owner's Name <br /> -, <br /> I Address <br /> icense# I� Business Phone <br /> Contractor's Name 4 t <br /> i,, ,t , EmergencTPhone (f" <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLWD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> ❑ : OTHER 11PUMP INSTALLATION 13 PUMP REPAIR <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL , 1.0CABLE TOOL Dia. of Well Excavation I "� PC Ky <br /> ❑ INDUSTRIAL <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia" of Well Casing <br /> j <br /> ❑ DOMESTIC/PUBLIC IJDRIVEN Gauge of Casing <br /> I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal VVV <br /> 13 ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION �-� <br /> L] DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> r Describe Material and Procedure <br /> y <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the for which this permit <br /> .r 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 for which this <br /> permit is issued, I shalt empl y persons subject to workman's compensation laws of California." <br /> 'I call to a out I ion prior to grouting and a final inspection. ^^ <br /> Title:'q /� Date: <br /> Signed <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By ' <br /> Additional Comments:Phase II Grout inspection P til <br /> I I Inspection <br /> 'f - pate Inspection By Date <br /> Inspection By " , <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH" -❑ January 1 & eceived 8y January 31 ❑ July 1 S ReceiveduIy 31 <br /> REMIT <br /> BILLING REMITTANGE $ LINT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <.- ...+. •d '-F: - <br /> LESS 1 <br /> PRORATION <br /> PLUS t <br /> PENALTY - - <br /> OTHER <br /> 4 <br /> OTHER <br /> Date -' " Receipt No'— .Pe it o. Issuance Date Mailed, Delivered <br /> Received by - 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />