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- Applications Will Be Processed When Submitted ProperlyCompleted Be SureToSign TheApplication. <br /> FOR OFFICE.4�.. APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is y <br /> made in compliance with San Joaquin County rdinance No. 1862 and the rules and regulations of the San Joa Sin oval Health District. "`"'�� <br /> Exact Site Address :5 :7 City/Town e <br /> .. I <br /> Owner's Name Phone <br /> Address City `~'"" <br /> Contractor's Name Licens # l�372-sC Business Phone 4 �. --?�_7 6 <br /> Contractor's Address ZeDAg - i E ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION 1:1WELL ABANDONMENT C1OTHER 11PUMP INSTALLATION ❑ PUMP REPAIRS <br /> *� REPLACEMENT❑ <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 © CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing N <br /> 9 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal y - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information_ <br /> ❑ GEOPHYSICAL Surface Seal Installed B'y: <br /> PUMP INSTALLATION: Contractor <br /> IF <br /> Type of Pump r t H.P. X_ <br /> PUMP REPLACEMENT: ❑ State Work Dane Iq CA <br /> PUMP REPAIR: a State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ • <br /> Describe Material and Procedure x <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 District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhichthis 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 311 call fora Grout Inspection 3or to gr u ing and a final inspection. Aw,� <br /> rs f Signed itle, J�t.S Date: G 7°' <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �- Application Accepted By Dat <br /> Additional Comments: <br /> Pha 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By��; '- Date l`a6w�y <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JWY 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 3 <br /> OTHER <br /> p�IQQ <br /> ``ti 7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered -+ <br /> APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ^� <br />