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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ^ y <br /> FOR OFFICE USE: APPLICATION <br /> s - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa pin County Ordinance No. 1862 and the rules and regulations of the San Joaqui Local Health District. <br /> Exact Site Address ,. I 9 S llrlr ty/Town �'Cq q <br /> Owner's Name �!!7 Phone (x3 " �<� l <br /> Address —Q14645 + ``-. "'xA0/a City <br /> Contractor's Name Q� Ti ^"� /1J License#,.27*7/4 Business Phone' a o 7 <br /> Contractor's Address - o"Z003; -,`Z 7 No-1 Emergency Phoney cS14 r" q � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes IVfl+-- No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT W <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: State Work Done R�e indL-e_ sw <br /> PUMP REPAIR: - ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t� <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 w'N"call for a Grout InspecHon prior to grouting and a final inspection. <br /> Signed X Title: _ DateAv T� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY # <br /> PHASE <br /> Application Accepted By, �Date � <br /> Additional Comments: <br /> Ph se II Grout inspection se I Final Inspection <br /> Inspection By Date Inspection By Date �Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLINGREMITTANCE $ REMIT <br /> BASE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> t AMOUNT I <br /> FEE S 8 �» <br /> LESS <br /> PRORATION <br /> l <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> � <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed WelivBred <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br />