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'Applications Will Be-Processed When Submitted ProperlyCompleted. Besure iosign ineuppllcauan. f. <br /> JSE: APPLICATION J k <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ' <br /> " ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I ' S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installtheworkherein described.Thisapplication,is t1� <br /> made in compliance with San Joaquin County Ord'na ce N1862 and the rules and regulations of the San aquin Local Health District. <br /> Exact Site Address�� _a - City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License i �y/ _ Busines Phone- Z /D <br /> t Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No 1 <br /> TYPE OF WORK (CHECK): NEW WELL Io DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I / 1 <br /> DISTANCE TO NEAREST: Septic Tank# Sewer Lines Pit Privy <br /> �� <br /> Sewage D'Isiposal Feld 1 Cesspool/Seepage Pit ��-' Other <br /> Property Lin 1n�Private Domestic Well . Public Domestic Well <br /> INTENDED USE TYPE OF WELLl 2 Jr <br /> ❑ INDUSTRIAL ❑.CABLE TOOL Dia. of Well Excavation <br /> sa <br /> ] DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information ' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: rzri <br /> PUMP INSTALLATION: Contractor N <br /> Type of Pump H.P. <br /> Q <br /> ❑ State Work Done <br /> t PUMP REPLACEMENT: VI <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County _Z1 <br /> L ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. --� <br /> Home owner or licensed agents 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for whicritriis <br /> permit is issued, l shall employ per ons subject to workman's compensation laws of California." <br /> f I will for a Gr t In ect' for to grouting and a final inspection. <br /> ' Signed X Title: �Ci�I Date: <br /> r oc <br /> (Draw Plot Plan on Reverse e) <br /> ��}}// FOR DEPARTMENT USE ONLY .g <br /> PHASE I �G3'l, - /O '��'�/ <br /> Application Accepted By Date <br /> Additional-Comments: <br /> Phase II Grout Inspection phase III Final inspectionCC�� .--,,,�� ���� <br /> Inspection By Date Inspection By 1 Date 75-Y�is7 ay <br /> G�-1 - , �/- - w, s, <br /> I D <br /> a I`ee is Due:_❑ ANNUALLY ❑ PER UNIT -❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT TAIVIOUNT <br /> CHECKED <br /> f DATE DATE REMITTED <br /> FEE <br /> I <br /> LESS f <br /> r PRORATION <br /> i PWS <br /> p PENALTY - <br /> OTHER <br /> OTHER <br /> w <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 AYE.,P.O.Box 2009 STOCKTON,CA 96207 ., <br />