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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> FOR_OFFICE USE: cd n?J APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT - PUMP&WELL` <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work,herein described.This application is <br /> made in compliance wit San Jo quip C u ty in nce N . 1862 a the rules and re ulations of the SaJoaquin Loc9l District. <br /> Exact Site Address City/To n <br /> Owner's NameMfrr Phone y <br /> Address ! S., City ors_ <br /> Contractor's Name License# L', A 7Zr—Business Phone <br /> Contractor's Address oa- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes_ X No , <br /> TYPE OF WORK (CHECK): NEW WELL El' DEEPEN ❑ RECONDITION❑ DESTRUCTION 13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRJ9 <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 x Public Domestic Well <br /> INTENDED USE TYPE OF WELL _1% <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - [ , <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .�' •4S 1�� H.P.Lam' -- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11( <br /> State Work Done -_ - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depths <br /> Describe Material and Procedure - <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. ` •I <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit C <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 T <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.';, <br /> 1 ill call for a Grout Inspecto ri grou 'n and a final Inspection. <br /> Signed itle:- A-r Date: } <br /> (Draw Plot Pran on Reverse Side) <br /> I <br /> F DEPARTMENT USE ONLY <br /> PHASE f <br /> Application Accepted By Dat�z�% <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection I <br /> Inspection By Date Inspection By bate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January,1 8 Received Ry January 31 ❑ July 1 &Received By July 31 <br /> .,, REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION jj s <br /> PLUS f f <br /> PENALTY I / <br /> a <br /> OTHER rry <br /> OTHER <br /> L -7 �i -137 <br /> 4. <br /> „ Received 6y>t -- Date Date Receipt No. Permit No. Issuance Date Mailed Delivered S <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />