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JR OFFICE usE: .+PPIlcanons" will taeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION <br /> µ (For Non-Transferable, Revocable, Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRiPLkCATE) WATER QUALITY .0141 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework 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_ / ;4P_* »r �r�/ <br /> City/Town <br /> Owner's Names - <br /> Address` r Phone <br /> Contractor's Name . City <br /> Contractor's Address �gl �� --Alip #�_ Business Phone ,�c7 . r <br /> --�`�`a-�+'�'P—:�-'� � yS <br /> Is Certificate of Workman's Compensation Insurance on File With SI/ mergency Phone <br /> Emergency <br /> JLHD? Yes _ <br /> TYPE OF WORK (CHECK); NEW WELL L �DEEPEN ❑ -° +� No 0 <br /> WELL CHLORINATION ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> --��-�� Sewer Lines Pit Privy _ <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> OtherProperty Line_ _fPrivate Domestic r <br /> Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ 1NDUSTRiAL ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE Dia, of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing " <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATIONGauge of Casing <br /> A GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION <br /> ❑ DISPOSAL 4 ROTARY Type of Grout ' <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Surface Seal Installed By: + f ♦ dJJ <br /> Contractor r <br /> PUMP REPLACEMENT: Type of Pump H.P. <br /> ❑ State Work Done— <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure —--- Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y <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 a Gro t Inspection prior to grouting and a final inspection. <br /> Signed X a <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE i FOR DEPARTMENT USE ONLY <br /> Application Accepted By y �� <br /> Additional Comments: Date ` <br /> PhaGrout I pectton <br /> Inspection By_ rs hase-Ill i Inspection <br /> ate —d' Inspection By 9� <br /> r gate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE � <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE g REMI <br /> z DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE p AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 'w <br /> Received b <br /> y ate Recerp;No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES o. I suance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />