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Appl n yk(turps d pert' mltted Properly Completed. Be SureToSign tnewpplcanna. <br /> FOR OFFkCE USE: iIIJJJs�y �►PPLICATICN <br /> Lf UI For Non! sferable,Revocable, Suspendable) PUMP&WELL <br /> AUG 17 <br /> IRONMENTAL HEALTH•PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE)SAN JO,,-.I U I N i OCAL <br /> Application is hereby made to the Lao <br /> � I lstnctforapermittoconstrucland/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance o. 1862 and the rules and r gulations of the San Joaquin Local Health District. <br /> s City/Town !" - <br /> Exact Site Address <br /> r <br /> Phone 3 <br /> g � <br /> I � - . ._'�..� <br /> Owner's Name <br /> Address City <br /> { License# 3 Business Phone <br /> Contractor's Name <br /> Contractor's Address '�� � � � Emergency Phon y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes O N❑ <br /> r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 1-1RECONDITION13DESTRUCTIOOC <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 1 <br /> REPLACEMENT❑ --- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C. <br /> Sewage Disposal.Field Cesspool/Seepage Pit Other <br /> # Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ,1 1�USTRIAL 1-1CABLETOOL - F Dia:of Well Excavation <br /> P <br /> L1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ► ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information R <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ff-State Work Done <br /> PUMP REPAIR: El 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. y <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, 1 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:111 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> 10 , i Date: <br /> Signed X 4 A E Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: Y <br /> ► Phase 11 r Inspection �! y ha III Final Inspection } ; <br /> a- r_ - � _ Inspection By Date <br /> Inspection By Date B. <br /> d.: PER � t <br /> '' -� �6❑ EACH a ''�0.January t'&Received'By January 31' ; ❑ July 1&Received By July 31 <br /> Fee Is Due: D'ANNUALLY ❑ PER UNIT ❑ PER SITE �" REMIT <br /> BILLING -`A} REMITTANCE•p _ r' $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION. DATE-,'�"' 'k ]ATF REMITTED IAMOUNT <br /> .A t� <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t - <br /> OTHER <br /> Received by <br /> Date Receipt No.- Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />