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�. Applications Will Be Processed When SuAPPLICATIONp e <br /> H FOR OFFICE USE: Ib <br /> C� (Fpr Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District a permit to construct and/or install the work herein described.This application Is <br /> Application is hereby made to the San Joaquin <br /> r rr�innaannce N 62 and the rules and regulations of the San foe ui Loc Hal# District. <br /> made in compliance with San Joaq .n Cou ty <br /> 6 ( City/Town <br /> Exact Site Address <br /> �f3 " Phone <br /> Owner's Name 9 City <br /> Addresse W IN Q►' T� 7^ o ���� <br /> ,, License# Business Phon <br /> Gontractor's Name Emergency Phone <br /> Contractor's Address No t <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes <br /> TYPE OF WORK (CHECK): WELEW L ABELLANDONMENT ❑DEEPEN ❑ OTH RRECONDITION <br /> PU❑MP INSTALLATION O❑❑ PUMP REPAIR <br /> WELL CHLORINATION V� <br /> REPLACEMENT❑ Pit Privy TT�� <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well <br /> Public Domestic Well W <br /> INTENDED USE TYPE OF WELL ! <br /> i. ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> I E4 IRRIGATION• ❑ ROTARY Type of Grout <br /> 13 CATHODIC PROTECTION <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL �I Surface Seal Instal d By: <br /> Contractor � <br /> PUMP INSTALLATION: ;�- N.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: El5tate Work Done <br /> 0 <br /> PUMP REPAIR: I State Work Done <br /> DESTRUCTION OF WELL:- <br /> Well Diameter Approximate Depth <br /> c r' Describe Material and Procedure <br /> 3L { <br /> I 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 Distr+ct.�_r <br /> ties the following:•"I certify that in the performance of the work for which this permit <br /> Home owner or licensed agent's signature certi } <br /> is issued, I shah not employ any person in such manner�as to become sut jeCt to Arkman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the tollowing:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California._' <br /> I will call for a Grout inspection prior to gr ti final 1 eclion. 1 f <br /> e. <br /> Date: <br /> Signed X - raw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI Da <br /> Application Accepted y <br /> : <br /> Additional Comments <br /> I Phase Ili Final Inspection <br /> t Phas I1 Grout Inspection By Date. <br /> l Inspection By Date Inspection <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH El January 1 8 Received By January 31 July 1 8 ReceivedJuly31 <br /> IT <br /> - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED a AMOUNT <br /> , <br /> FEE <br /> LESS , <br /> rE PRORAT4ON <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f <br /> S <br /> Receipt No. Permit No Is uance Date Mailed De4ivere`d <br /> Received by Date ; <br /> 1601 E.HAZELTON AVE-,P.O.Box 2009 �'STOCI(TON,CA 95201 <br /> APPLICANT�RETURN ALL COPIES TO: =ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />