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Applications Will BeProcessedWhenSubmitted Properlycompleted. Be sureTosign TneApplication. <br /> "YFOR,OPICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ° <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 with San Joaquin Cou-nly Ordinance No. 118,62 and the rules and regulations of the Sgp,J aquin Local Health Distri <br /> Exact Site Address W City/Town ? /Vi�L�llo <br /> Owner's Name Phone <br /> Address Q City. �- <br /> Contractor's Nam 1. �Icense# .9ff S� Business Phone <br /> Contractor's Addres .Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 41" No <br /> TYPE OF WORT( (CHECK): NEW WELL 93--DEEPEN 11 RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0--�PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Se7page Pit Other <br /> Property Line— Private Domestic Well 12.0 Public Domestic Well y�3 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DO_MF.STIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> L:3DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,❑,.,,,, G�RAVEL PACK Depth of Grout Se <br /> ❑ CATHODIC PROTECTION IF-ROTARY Type of Grout ��- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALrface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C , - <br /> Type of Pump H.P. -7 �I <br /> PUMP REPLACEMENT: ❑ State Work Done �1 <br /> PUMP REPAIR: ❑ 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. r_S� <br /> Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of thework 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:"I certify that in the performance of the work torwhich this <br /> >nedX <br /> rmit is issued, I shall emplo ersons subject to workman's compensation laws of California." <br /> will call for a Gr u s ct ph to grouting and a final inspection. <br /> St Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PH �,A _ <br /> Application Accepted B _ Date <br /> Additional Comments: <br /> Phase II Grout Inspection ` Phase III Final Inspection <br /> Inspection By ILn Date ` Inspection By Date <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE g <br /> \i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 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 952 / <br />