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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR,PFFJCE:USE: APPLICATION <br /> 12 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTWOERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY,,,,,,- IN <br /> IP <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations-of the San'Joaquin Local Health District. <br /> Exact Site Address � To <br /> L <br /> .0 <br /> Owner's Name 4 6 J /}2 12 _TPhone <br /> Address City <br /> Contractor's Name License ��� ? Business Phoriet t� j b �2_ <br /> Contractor's Address :. "'3 rfEmergency Phony <br /> Is Certificate of Workman's Compensation n urance on File_ With SJLHD? Yes t Na 1 <br /> TYPE OF WORK (CHECK) NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ OIL <br /> WELL CHLORINATION C3 WELL ABANDONMENT E] OTHER ❑ - .. PUMP INSTALLATION. PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Gt Sewer Lines P Pigg <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL a.. Dia. of Well Excavation l ` <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ,d 6 <br /> ❑ CATHODIC PROTECTION tv.ROTARY Type of Grout C aLc- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / S rface Seal Installed By: 61 <br /> PUMP INSTALLATION: Contractor O� V- Z.1-< k <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r « 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 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 Grout I ;pection prior to grouting and a final inspecton. r <br /> Signed X,, Q "s' Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / f <br /> Application Accepted By _ Date <br /> Additional Comments: k <br /> Phase II Grout Inspections t Fin t Inspection <br /> Inspection By Date T Inspection By Date. <br /> c <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT b PER SITE ❑ EACH '" ❑ January"I &Received By January 31 ❑ JWy 1 &Received By July 31 <br /> BILLING _'� " 'REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER - - <br /> Received by Date I Receipt No. - Permit No, - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMWSERVICES 1601 E.HAZELTON AVE,P.O.Box 2009 STOCKTON,CA 95201 <br />