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When Submitted Properly Completed. BeSureTo sign TneAppnoaUvn. <br /> Applications Wili Be Processed <br /> FILE USE: -APPLICATION <br /> �p. (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ATER(COMPLETE IN,TRIPLICATE S-I ifC;ILEW,¢' :97 QUALITY i?�_ D4CJation . <br /> ° � l <br /> Application is hereby made totheSan JoaquinLocalHealtliDistrict ora rmlttoconstructand/orinstalliheworkhereindescnbed.Thisappllcatlonls <br /> made in compliance with San Joaq in County rdinance No.1862 and the rul d regula Bons of the San Joaquin Local Health District. <br /> r✓O-+J /� ',,,:VO4 !" AftCity/Town <br /> Exact Site Address <br /> Owner's Name <br /> fe 7-Y".e– <br /> Phone <br /> City <br /> Address <br /> Contractor's Name License# F7usiness Phone <br /> Coptractor's Address mergency Phone <br /> No "— <br /> Is Certificate of Workman's Compensation insurance on File With 5J D? Yes I <br /> ClCONDITION 11 DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ t�� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> Sewage Disposal Field Gesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL W <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor y <br /> E Type of Pump H P ? <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 91 state Work Done �- <br /> PUMP RE-PAifi: Approximate Depth #r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that l 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. Q.. <br /> Home owner or licensed agent's signature certifies the following-"[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 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 Insp c n ri r'o outing and a final inspection. <br /> Signed <br /> Title: Date: <br /> (Draw P Plan on Reverse Side) <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IZ.? V <br /> • Date <br /> Application Accepted By k <br /> Additional Comments: _ <br /> Phase II Grout Inspection ,�? 11 al Inspection <br /> Inspection By <br /> Date Inspection By ZAP Date �� l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received-By January 31 ❑ July 1 &ReceiveMT <br /> RdEByI July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHMT <br /> ECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE L <br /> r LESS <br /> r PRORATION <br /> PLUS V <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Issu ce Dat Mailed Delivered <br /> 4. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 •- <br />