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f -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 /> _- PUMP&WELL <br /> �=x ENVIRONMENTAL HEALTH PERMIT <br /> /f•36' - <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetoth Sa oagti Health Districtfora permit to constructand/or install thework herein described.This application is <br /> made in compliance wit oa uin Cou t Ordinance o. 1862 and the rules and regulations of the San.4oaquin}ocal Health District. <br /> Exact Site Addi City/Town tI"`+'<tii <br /> Owner's Name e Phone <br /> Address �� City <br /> Tht <br /> Contractor's Name License ti Business Phone'Ii P 2- G <br /> Contractor's Addressce on FEmergency,Phone <br /> Is Certificate of Workman's Compensation Insuranile With SJLHD? Yes__ �— No d <br /> TYPE OF WORK (CHECK): NEW WELL, D€EDEN ❑ RECONDITION❑ No C> <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy `" <br /> Sewage Disposal Field0 Cesspool/Seepage Pith Other <br /> Property Line !�o __ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r T <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> fDOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ��, <br /> 11 IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information La <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> F PUMP REPAIR: ❑ State Work Done <br /> (f DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f <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. <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I will ca r a Grout Ens a ton prior to grouting and a final inspection. <br /> Signed X Title: r Date: 11 � <br /> ,100'(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE! �(�A C tQ . — <br /> Application Accepted By f .`t 1 Date <br /> Additional Conran its: <br /> Ph" 11 11 Inspection Phase III Final Inspection <br /> Inspection By Date — v Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UWT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM17TANCE $ AMOUNT DUE CHECKED <br /> tt DATE DATE REMITTED AMOUNT <br /> ' FEE q3 <br /> t <br /> LESS <br /> PRORATION / <br /> I PLUS L— <br /> PENALTY <br /> OTHER 3 <br /> OTHER <br /> r C51o L� <br /> r <br /> Received by Date" Receipt No. - Permit No, 14suancb Date Mailed Delivered <br /> r APPLICANT--RETURN ALL COPIES Ti ENVIRONMENTAL HEALTH PERMIT/SERVICES'" 1601 E.HAZELTON AVE.,P.O.Box 201- STOCKTON,CA 95201 <br />