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PPrcallons wm deProcessedWhen Submitted Properly G+?upl✓sted. Be Sure To Sign The Application. Y <br /> FOR OFFICE USE: APPLICATION <br /> &44 t�#LX' (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and a rules and regulations of the San cal Health District. <br /> Exact Site Address , l,,y a.3"GI ' <br /> City/Town <br /> Owner's Name trYit p <br /> Address Phone <br /> Int ,rte City <br /> Contractor's Name <br /> Contractor's Address a License#/13---7-147 Business Phone <br /> f u Emergency Phone <br /> Is Certificate of Workman's Compensation In on Ile With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DE=STRUCTION❑ <br /> WELL CHLORINATION ❑ <br /> REPLACEMENT❑ WELL ABANDONMENT 11OTHER ElPUMP INSTALLATION 11PUMP REPAIR® <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines (y} <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other N <br /> Property Line Private Domestic Well Public Domestic Well A <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC Dia. of Well Casing <br /> ❑ 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 • A til I: <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 11 State Work Done <br /> PUMP REPAIR: ® State Work Done r� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County L <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 w I tali for a Grout e ti for o gr luting a a final inspection. <br /> Signed X , <br /> lHe: Date: <br /> (Draw PI Plan on Reverse Side) -9/-Z13 � <br /> F DEP RTMENT USE ONLY <br /> PHASE <br /> Application Accepted By a <br /> Additional Comments: Date <br /> Phase II Grout Inspection Phase lil Final inspection <br /> Inspection By Date Inspection By <br /> Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT 3 PER SITE ❑ EACH ❑ January 1 Received 8 Januar <br /> Y Y 31 ❑ July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> t <br /> FEE AMOUNT <br /> �/(� � <br /> LESS <br /> PRORATION f <br /> PLUS l <br /> PENALTY �� F <br /> OTHER !� <br /> OTHER <br /> 4 <br /> Received by Date Receipt No. Permit No. ^� <br /> Issuance pate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.box 2009 sTOCKTON,CA 98201 <br />