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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION ,I <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL /y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE WATER QUALITY ,� 10 ot „,e <br /> ' Application is hereby made to the San Joaquin Local Health District fora permit to construct andlor.install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 arld the rules and regulations of the San Joaquin Local Health District.. <br /> 4 Exact Site Address �' � City/Town <br /> Owner's Name rg. j- ''� ' t- �`' Phone <br /> e 1�2-_? <br /> Address r7� �r:;3 ;sf . " Cit �> 1 <br /> Y �y <br /> Contractor's Name :`License#- l Business Phone � �Td <br /> Contractor's Address `� �� `' Emergency Phonem_ t, � �- ' Al <br /> Is Certificate of Workman's Compensation Insurance on File With S_JLHD? Yes No v <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ -DESTRUCTION❑ - ` <br /> ` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRW <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well f Public Domestic Well <br /> k <br /> INTENDED USE TYPE OF WELL <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 /> r ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT. 11 State Work Done j. <br /> uk <br /> PUMP REPAIR: T State Work Done Poo <br /> -49 IS, evil <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �1) <br /> rt - r <br /> Describe Material and Procedure ' <br /> t <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ? ordinanWs;state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i <br /> Homeowner 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 forwhich this <br /> w permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for rout I Clio rior to grouting and a final inspectio <br /> Signed X Title: <br /> 4_. Date: �p , <br /> (Draw Plot Plan on Reverse Side) <br /> ' F�1OR DEPARTMENT USE ONLY <br /> ' Mme= F • - <br /> PHASE I <br /> Application Accepted By ' - Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection rte} <br /> Inspection-By Date r' Inspection B Date ` <br /> Fee Is Due: ❑ ANNUALLY ❑'PER UNIT rt ❑ PER SITE ❑ EACH ❑ January 44eceived By January 31 > ❑ July 1 &Received By.July 31 <br /> REMIT <br /> BILLING a REMITTANCE $ <br /> AMOUNT DUE C <br /> BASE. EXPLANATION CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE VL . <br /> `LESS .4 . r. . <br /> PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER } r <br /> .35 f <br /> { Received by -I Date - Receipt No. ° Permit No, Issuance Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES -'1601.it"HAZELTON'AVE.,.P.O:Box 2009 STOCKTON,CA 95201 rY <br />