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Appllcations Will Be Processed When Submitted Properly Completed.Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable;Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE} li WATER QUALITY <br /> r a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District fo <br /> made in compliance with San Joaquin Count Ordinranc No.1862 and the rules and regulations of the Sa oaquin Local Health District. <br /> Exact Site Address W City%Town <br /> w. Phone' Sd7 <br /> Owner's Name1� <br /> , Address '' `` - City -' y <br /> Contractor's Name � �f-� ``` ` License Business Phone <br /> i'' s. `Emergency Phone <br /> Contractor's Address - � <br /> Is Certificate of Workman's Compensation Insurance on lie Witfi SJLHi?? Yes <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECO DESTRUCTION❑ <br /> WELL-CHLORINATION ❑ WELL ABANDONMENT 13 OTHER <br /> PUMP INSTALLATION ❑ PUMP REPAIR 13 <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 /> ❑ IISSTRIAL n ❑ CABLE TOOL Dia. of Well Excavation <br /> W DOMESTIC/PRIVATE 1:1 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ' 4 ❑ GRAVEL PACK' Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL l ❑ OTHER Other information <br /> f �; Surface Seal Installed By:: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor, ; <br /> Type of Pump H.P.L� <br /> PUMP REPLACEMENT: j ii: 11State Work Done <br /> PUMP REPAIR: <br /> :3 ❑ State Work Done <br /> DESTRUCTION OF WELL:. Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ii <br /> Thereby certify''that 1 have prepared this application and that the work will be done in accordance with San Joaquin County r <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 /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this y <br /> # permit is issued', I shall employ persons subject to workman's compensation laws of-California." <br /> r Grou on prior to grouting and a final inspection: <br /> Signe X Title: Data: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 6 -91 <br /> i <br /> Apply atlion Accepted By R Date -- �— <br /> Additional Comments: <br /> P e II Grout Inspection Pha I al inspection/ <br /> Inspection B Date Inspection By Date <br /> iBy <br /> Fee Is Due: 11 ANNUALLY '❑ PER UNIT- El PER SITE - © EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITuIy 31 <br /> ii BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS j ill <br /> PRORATION - <br /> PLUS a A <br /> PENALTY !6 <br /> OTHER it - <br /> OTHER J <br /> Received by Date 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 2405 STOCKTON,CA 95201 <br />