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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendabfe) ( PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMITS S3 <br /> (COMPLETE IN TRIPLICATE] ~tk WATER QUALITY �11�. L �Tf � ✓"� f <br /> Application is hereby made to the San Joaquin Local wealteh District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance San. aquin unty�Ordinance No. 1862 and the rules and regulations of the Se�,Joaquin Local ,iealth District. <br /> Exact Site Address "� -dam City/Town �7�JrR Ly.. t � �7 <br /> Owner's Na a Phone <br /> AddressC_ • CitY <br /> Contractor's Name 6`� License#3a�'L`'_7t� Business Phone � O <br /> Contractor's Address �� `� Emergency Phone <br /> Is Certificate of Workman's Compens tion Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,N,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION �` PUMP REPAIR❑ _� <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 /> ❑ I'yWSTRIAL ❑ 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 Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t Surface Seal Installed By: <br /> / <br /> PUMP INSTALLATION: Contractor ; r%a �.L� , <br /> Type of Pump H.P.Z3 <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 -may <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. V' <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> a Grout R�Sptrionnprlor 10 grouting and a final inspection. <br /> Signed X - <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By_ . _ % '�— Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 10 Final Insoction <br /> Inspection By Date <br /> Inspection By Date -Z � <br /> r <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 R Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> i LESS <br />[ PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fff 04 <br /> D1�s;_;L� 111114 hz) a a,dr, <br />.6 Received by Date Receipt No, Permit No. 1 uance 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 /> V <br />