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App o W>wIBeProcessed -,en Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: �+ c�3 19 . APPLICATION <br /> QU 1 (Fc + ansferable, Revocable,Suspendahle) <br /> PUMP&WELL <br /> VNMENTAL HEALTH PERMIT ` <br /> (COMPLETE IN TRIPLICATE) StSWATER QUALITY <br /> Application is hereby made to the San &qulnLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co my Ordinanc.,%No.1862 and the rules and regulations of the San Joaquui Local Health District. <br /> Exact Site Address V City/Town (v7�-o__ <br /> Owner's Name -al o_+_ Phone 2 g 7 <br /> Address � d City <br /> Contractor's Name License# q&0& Business Phone 23- `T / <br /> Contractor's Address _ �O./ w/0 �yl � _ Emergency Phone —� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATIONlb�� 13 GRAVEL PACK Depth of Grout Sea[ <br /> ❑ CATHODIC P T CION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �7 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump n F H.P. O z" <br /> PUMP REPLACEMENT: ®tate Work Done PZ .ager _gL .0- <br /> PUMP <br /> 2PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I ' <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 /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wilcall fora Grout Inspection prior to grouting and a final inspection. <br /> Signed X j� Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date t <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection ByDate JSP " <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �ecl_ �X + — f 1 2 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER M -m 2 11 .q <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 2009 STOCKTON,CA 95201' , <br />