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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 4 (For Non-Transferable,'Revocable, Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH"`PERMIT <br /> . ,. <br /> (COMPLETE IN TRIPLICATE) � e WATER.QUALITY.i <br /> _ ... ;°'!• J .jApplication 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 compliancewitIl San Joaquin Cou O dinance No. 1662 d t e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address - 6 0 A41 City/Town <br /> i <br /> Owner's :'� Ptione <br /> Address vim,. . F. Gity Q <br /> Contractor's Name 171 9 Iii " License# f '` Business-Phone' <br /> Contractor's Address }` t.3 1tA11 B " JIr 'I" '' Emergency Phone <br /> Is Certificate of Workman's Compensation n rance on File With SJLHD? Yes No F <br /> YPE OF WORK (CHECK): NEW-WEbLr_ _DEEPEN ❑­ RECONDITIO Y <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑. PUMP INSTALLATION UMP 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 /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation!' i <br /> >�_D,OMEST]C/PRIVATE k ❑ DRILLED Dia. of Well.Casing (� — <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 71 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL. !. Surfa Seal Installed By: rad <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done . <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure a <br /> ( <br /> hereby certify that 1 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 /> s <br /> I will call for a Grout Inspectl r grouting and'a final inspection. - _--- <br /> Signed X Air. Title: amu`. Date: <br /> I' (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I u In <br /> i M <br /> i t <br /> Application Accepted By - Date f <br /> T }� <br /> Additional Comments -01: <br /> Ph 9e It Gro 1 Inspection - � ase IH in* Spec17 ion 1 <br /> Inspection By ate Inspection By tol^�° r r <br /> Fee IS Due: ❑ ANNUALLY' ❑ PER UNIT © PER SITE ❑ EACH ❑ January't&Received By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE t $ _ - <br /> 'BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE' REMITTED AMOUNT <br /> FEE - -- , <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY: <br /> .... ... <br /> OTHER + i. <br /> OTHER <br /> Received by_. - Date I Receipt No. Permit No. Issuance 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 />