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,.Applications Will Be F cessed When Submitted Properly Completed. Be Sure To Sign The A f <br /> 9 PP4 cation. <br /> FOR OFFICE USE:_ ' _ ... APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable)-' PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ~ <br /> (COMPLETE INTRIPLICATE) WATER QUALITY <br /> Application is'hereby made to the San Joaquin Local Health Districtfora permit to construct andlorinstallthe work herein described.This application is <br /> made n compliance with San Joaquin CoOrdinance No. f 862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (? 3 unE �� 41-71-4City/Town 4 'y <br /> Owner's Name OG/ Phone GCp a <br /> Address /� GO city—&4STn 47 <br /> Contractor's Name r License S BusinessPhone�` 9 / o� <br /> Contractor's Addres .S� mergency Phone 4/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): -NEW WELLEl­-�EPEN ❑ ' RECONDITION❑ DESTRUCTION❑ t1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®''PUMP REPAIR❑ r"_fit <br /> REPLACEMENT❑ , ' I fV,,� <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy _ V ' <br /> Sewage Disposal Field Cesspool/Seepage Pit 1 A R Other k <br /> Property Line YQ . Private Domestic Well Public Domestic Well <br /> INTENDED USE ' TYPE OF WELL <br /> ❑� <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> El- <br /> �I70MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1691 <br /> ❑ DOMESTIC/PUBLIC l' ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION e ❑ GRAVEL PACK Depth of Grout Seal —� <br /> ❑ CATHODIC PROTECTION 'PE5,49TARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. l �� <br /> PUMP REPLACEMENT: ❑ State'Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ii' Well Diameter Approximate Depth <br /> F Y <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit r <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 fpr which this k r <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 groutin and a final inspection. <br /> Signed )( ,.. Title: <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE _ <br /> Application Accepted By Date/.-"9 ; <br /> Additional Comments: <br /> Pha a II Grout In ec tn Phase,411 Final Inspection 1-- <br /> Inspection By f ' Inspection 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 /> BASE 1-! EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> y AMOUNT <br /> FEE F <br /> LESS <br /> PRORATION - 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <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 95201 - <br />