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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) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> k <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 18 2 and the rules and regulations of the San Jo quin L cal Health District. <br /> Exact Site Address City/Town a��'' <br /> Owner's Name l'l L�f ^� Phone <br /> Address �L �- �'.b'l a r -. City— '- <br /> Contractor's Name License Business Phone2_1 0 <br /> Contractor's Address Z- Emergency Phone <br /> Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes � No _ + <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION0PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <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 /> 9�-TO_MESTIC/PRIVATE 12�'6R LLED Dia. of Well Casing E <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing <br /> �lRIRiGATION 11 GGR VEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 9 OTARY Type of Grout Lel/Xe <br /> ❑ DISPOSAL ❑ OTHER Other Informations <br /> ❑ GEOPHYSICAL Sitrface In tailed By- <br /> PUMP INSTALLATION: Contractor .f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> \ I <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 the work forwhich 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 /> Lxil.Lcall fora Gro t Inspection prior to grouting and a final inspection. <br /> Signed Title: � Date: 9/Z3 .+� <br /> (Draw Plot Plan on Revers/Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date_ fY 1 <br /> Additional Comments: l� <br /> Phase it Grout Inspection Phase III Final Inspection <br /> Inspection By 13 Date ZU 75 inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 -- - <br /> BILLING REMITTANCE $ REMfT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - 4 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Ihsuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 <br />