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I` m Applications Will-Bi:Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> f <br /> (For Non-Transferable, Revocable, Suspendable) , <br /> (((///11V✓✓ <br /> ENVIRONMENTAL HEALTH PERMIT PUMP`&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit toconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin qounty Ordinanc No. 862 a d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1 C. �� City/Town S''Tcsc <br /> Owner's Name Phone �' -0 - <br /> Address City,_[6!6� / - <br /> I Contractor's Name f? License Business Phone, <br /> Contractor's AddressWf� _Emergency Phone 47tif !33 <br /> i Is Certificate of Workman's Compensation Insuran a on File With SJLHD7 Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 14— PUMP REPAIR❑ <br /> I REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /ig Pit Privy <br /> Sewage Disposal Field I!� — Cesspool/Seepage Pit Other <br /> Property Liner, 1 Private Domestic Well Public Domestic Well_ A.o c_� <br /> INTENDED USE TYPE OF WELL <br /> ❑�/INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> R <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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor M / V P v <br /> Type of Pump 17 H.P. <br /> { PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> 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 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 Groj4 Inspection pri r to grouting and a final inspect' <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I ��� <br /> Application Accepted By__. .j��Ju` - - Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a fl Final Inspection , 7 , <br /> Inspection By Date Inspection By �+�^ Date / <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT Cl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 63LLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> Ck <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> f OTHER <br /> ` OTHFR <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />