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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR QFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoagLiin Copy Or ance N . 186 he rules and regulations of the San Jg�q In� l Welt District. <br /> Exact Site Address JCity/Town � <br /> Owner's Name �f �" Phone <br /> Address City <br /> Contractor's Name License Business Phone' <br /> w <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With-SJLHD?;—Yes <br /> TYPE OF WORK (CHECK): NEW WELL `DEEPEN ❑ RECONDITION❑ - DESTRUCTION <br /> WELL,CHLORINATION ❑_._.,.W.ELL,ABANDONMENT.b__.. .OTHER©.-._.P_UMP INSTALLATION ❑ + PUMP.REPAIR❑ <br /> REPLACEMENT❑ �+ t <br /> DISTANCE TO NEAREST: Septic Tank �a Sewer Lines. / Pit Privy <br /> PCF l <br /> Sewage Disposal Field ^-r" Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 0_/)3.9- Publiic)Domesti q.Well e7 4- <br /> INTENDED <br /> -INTENDED USE TYPE OF WELL l t� <br /> I] INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED ! Dia. of Well Casing,- <br /> DOMESTIC/PUBLIC DRIVEN I Gauge of Casing ' <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1� I <br /> ❑ CATHODIC PROTECTION ROTARY f Type of Grout <br /> 11 DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL I �8�, ac I nstalled y:PUMP INSTALLATION: ContractorAO's � °L' <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT:.._...._.:...,,.. ❑ State Work Done <br /> PUMP REPAIR: _�! ❑ State Work Done <br /> DESTRUCTION OF WELL: . Well Diameter A0,roximate 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. e <br /> Home owner or licensed agent's signature certifies the following."I certify that in the performance of the work forwhich 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 /> s _-r <br /> Contractor's'hiring orsub-contracting signature certifies theffoiiowing:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persens-sn6j-E;ct to workman's compensation laws of California." <br /> I r s <br /> I II for ro inspection-prior-to grouting and.aJinal inspection. <br /> Signed Title: „Gate: <br /> If <br /> (Draw Plot Pian on Reverse Side) <br /> ' <br /> FORDEPARTMENTUSE ONLY % <br /> PHASE I �' 1 <br /> Application Acce ted By \at_,�nt Date s^ 8a <br /> .'y <br /> Additional Comments: <br /> ase 11 Grout Inspection �J �� nspectlon ) <br /> Inspection By Date / ��� Inspection By Date <br /> i <br /> I <br /> = Fee Is Due: ❑ ANN UALLV El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eivetl By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> i <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE JEXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> .a11f'' ♦' if;' �tj� <br /> FEF rs. [�J�� <br /> PENALTJ <br /> OTHER <br /> OTHER <br /> i Received by Date .. Receipt No. Permit No. ss e - . all. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 \ <br /> t - <br />