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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (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 fora permit to construct and <br /> made <br /> install the work'herein{described.This applicatioA is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re lations bf t an Joaquin Local Health District <br /> +'i <br /> Exact $ite'Address #off$ 5 �. 3,,r .3. �5 L.i c' f yld�• — 7c�D�J.''01'eulia ,:k <br /> Owner's Name Phone <br /> Address 62 9. '�. .e , ,..; City <br /> Contractor's Name fl.License#�' -/� <br /> n ` Business,Phonen + <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No t <br /> TYPE-OF WORK (CHECR):�"" NEW-WELLX'--DEEPEN-❑ >._RECONDITION❑ ` DESTRUCTION❑'_=' <br /> WELL CHLORINATION ❑. f WELL..ABANDONMENT CIOTHER.0 PUMP-INSTALLATION ElPUMP REPAIR 11 - <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:fiSeptic Tank 'Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> K Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE' f' TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing a O <br /> ❑ DOMESTIC/PUBLIC ' ❑-DRIVEN" Gauge of Casing Z160 aeaut� <br /> ❑ IRRIGATION. <br /> - , -,�-�-: �.. ��GRAVEL PACK Depth of Grout Sea! <br /> ❑ CATHODIC PROTECTION_`"' XROTARY Type of Grout <br /> 0 DISPOSAL. "." ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: .`: .r`` Contractor <br /> "Type of Purnp H.P. <br /> PUMP REPLACEMENT: ❑.State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure r <br /> i <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will all for a Grout Inspect rior to grouting a d a final inspection. <br /> Signed X' - le: Date: a <br /> # (Draw PI Ian on Reverse Sid ) <br /> } FOR DEPARTMENT USE ONLY <br /> PHASE 1 _ - <br /> r <br /> t <br /> Application Accepted.By �_ Date <br /> r Additional Comments: <br /> has I Grout Inspection -_;/,p Phase III Final Inspection <br /> i inspection By Date Inspection By Date <br /> Fee Is Due: ❑ 'ANNUALLY []'PER UNIT - 0 PER SITE ❑ EACH ❑ January 1 8 Received By January 31 El July 1 &-Received By July 31. <br /> REMIT <br /> g BASE- -EXPLANATION - �-. BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT-DUE CHECKED <br /> t AMOUNT <br /> FEE f <br /> — « <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I — <br /> A F <br /> w OTHER 1._.. <br /> `,ed by Date_ Receipt No.'- ° Permit No, _ Issu ce ate Mailed Delivered <br /> LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES�'- _ 1601 E.HAZELTON AVE.,,P.O.Box 2009 STOCKTON,CA 95201 A <br />