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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign-The Application.T' / <br /> APPLICATION '" <br /> FOR fa3FFICE USE: 7 <br /> (For Non-Transferable, Revocable, Suspendable) jf <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE) <br /> WATER QUALITY ! �3 — -55-v --0 7 <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 Jo quin County r finance 862 and th r les and regulation of a San Ja uin Local Health District. <br /> Exact Site Address _ � Y/ <br /> i <br /> Owner's Name — Phone <br /> Address 05- City <br /> Contractor's Name License# 2?1, Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No II <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O�f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ C' r� I / <br /> DISTANCE TO NEAREST: Septic Tank �-o Sewer Lines c (Zf# Pit Privy l <br /> Sewage Disposal Filld J 06 Ce sspool/Seepage Pit Other <br /> Property Line ( Private Domestic Well 25r46 Public Domestic Well -- <br /> INTENDED USE TYPE OF WELL <br /> { <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation -- <br /> f� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> XIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: n J 66C O <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump HflrJ H.P. <br /> i <br /> PUMP REPLACEMENT: ❑ State Work Done -' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> i 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 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 /> I Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons s ject to workman's compensation laws of California." <br /> I will or a Grout , spec Irri 7p !"r 1 grouting and a final inspection. t <br /> Date: <br /> Signed X Title: <br /> (Draw Plot Plan on Rev r� ide) <br /> FOR DEPARTMENT USE ONLY <br /> j PHASE I <br /> Date <br /> Additional <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> t Inspection ByNN a Date Inspection By ` -- Dated <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ��-QO l � <br /> Received by Date Receipt No. Permit No. Iss ance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />