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- " Applications Will Be Processed When`Submitted Properly Co OI teld:f6'trSure ToSignThe,��p ipation. <br /> �aR-OFFICE USE: APPLICATIO �.� <br /> (For Non-Transferable, Revocable, Suspe" <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT! <br /> I .� N/ WATER QUALITY SAN I1 t T <br /> (COMPLETE IN TRIPLICATE) y' V� v7y ��r Q f�r�i T;. tr-�.�iT��C <br /> Application is hereby made to theSanrJoaquin Local Health District fora permitto construct andror install thework herein described.T 's application is <br /> made in compliance wit an Jo 1ounty Ordinanco. 1862 and t u s and regulations of the San dgaquin Local s ict. <br /> ea <br /> Exac i Address 0~Q'll I. <br /> e City/Town C. <br /> Ow r ame Phone <br /> �c f <br /> Address q ty <br /> Contractor's Name I� License# sinessl P <br /> Contractor's Address I��I Emergency Phone "� <br /> li <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes N <br /> TYPE OF WORK (CHECK): NEW WELL El"' DEEPEN ❑ RECONDITION❑ DESTRUCT <br /> WELL CHLORINATION ❑ WE`LL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIO PUMP REPAIR E] j <br /> REPLACEMENT❑ ;I ,f— /_ <br /> DISTANCE TO;NEAREST: Septic! Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Prop ierty Line Private Domestic Well _ Public Domestic Well - <br /> INTENDED USE I TYPE OF WELL Z5 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing , <br /> 11DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal } <br /> ❑ CATHODIC PROTECTION iii LL OTARY Type of Grout <br /> ❑ DISPOSAL13OTHER Other Information_ <br /> ❑ GEOPHYSICAL 0dy^ Iti° Surface Seal Installed By: <br /> PUMP INSTALLATION. U Contractor1. } <br /> �I Type of Pump H.P. <br /> PUMP REPLACEMENT; ElState Work Done <br /> PUMP REPAIR: 13State Work Done <br /> DESTRUCTION OF WELL: f Well Diameter Approximate Depth <br /> /} ON11 y�, Describe Material and Procedure I <br /> accordance with San Joa uin County <br /> I hereby certify that I have prepared this application and that the work will be done In c q <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or Iicensedlagenl'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 /> I <br /> Contractor' Ing or sub-cont Ing signature certifies the following:"I certify that in the performance of the work for which this <br /> per. s ed, I shall'em p y pe sons subject to workman's compens tion laws of California." <br /> I i <br /> I ill out In's tion for to rquting and a final inspec <br /> ..� Date: 0 <br />` Signed X �� Title: - <br /> (Draw Plot Plan on everse Side) <br /> R D ARTME USE ONLY ' <br /> PHASEI 2/ <br /> Application Accepted By p <br /> i rJ� Date I <br /> Additional Comments: <br /> haglP rout Inspection �/ /fit, P e I Final pectin <br /> r �.1 I <br /> Inspection By Date Inspecti By <br /> Lt Fee is DED]ue: ANNUALLY i ❑ <br /> �' <br /> 4 PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT } <br /> '! BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EASE EXPLANATION <br /> L DATE DATE REMITTED AMOUNT °I <br /> fI <br />` FEE ��p` ���• <br />` LESS <br /> PRORATIION II <br /> PLUS <br /> PENALTY <br /> OTHER III <br /> OTHER, <br /> Received by Datel� Receipt-No. Permit No. I uance Date Mailed Delivered <br /> APPLICANT.-RETURN ALL GOP I S TO:.. ENVIRONMENTAL HEALTH PERMIT/SERVICES 7_ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />