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Applications Will Be Processed When Submitted Properly Completed,Be Sure To SignTheApplication. A <br /> 1- FOR OFFICE USE: APPLICATION <br /> w. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT'... <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 County Ordinance No. 1862 and the rules and regulations of the Sart Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> City.:: <br /> Ad <br /> ress <br /> Contractor's Name "License#'�.. -s Business Phone 23 _.�7gr7 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No ' <br /> TYPE OF WORK (CHECK): NEW WELL❑" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ 1 <br /> REPLACEMENT® y <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <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 1f ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTI8/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATI6.N'"t ❑ GRAVEL PACK Depth of Grout Seal ` <br /> ❑ CATHODIC"PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL, f ❑ OTHER Other Information' <br /> 11GEOPHYSICAL. r: <br /> Surface Seai Installed.By: <br /> PUMP INSTALLATION: Contractor !4_ '..`'' <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:— Well Diameter - --Approximate Depth--b- <br /> 'nescrabe Material and Procedures:= <br /> �.. � _.,,,;t.-.r�a fir.:= •�� . .� <br /> I hereby certify that-] have prepared this application and that the work will be done in accordance with San JoaqlCalifornia." <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 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fo <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I will cW1 for a Gr ut Inspection pAor to grouting and a final inspection. <br /> 11104 1 Title: _ Date: <br /> Signed X —ala_ 4ft2 <br /> (Draw Plot Plan on Reverse Side) <br /> ` ) F R DEPARTMENT USE ONLY <br /> PHASE I -tel <br /> Application Accepted By , Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection 411, <br /> 1 Inspection Z <br /> Inspection By Date Inspection By- Date <br /> Fee Is Due: ❑ ANNUALLY ❑'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 4 &Received By July 31 <br /> REMIT <br /> BASE" 'EXPLANATION :BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> g � o <br /> FEE / <br /> LESS ` <br /> PRORATION <br /> 4 <br /> Y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -- Date - Receipt No.- - Permit No.-. _ •i uance 0ale. Mailed. _ —Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />