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r Appllca iii&@ Be PlC66QSsed When Submitted Proa re ly Completed. Be Sure To Sign The Application. / <br /> FOR OFFICE USE:: APPLICATION <br /> SM vl€ '�,i�ytvlj` i.r,#W-Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> 1 HEALTH IDIS R" NVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 'WL <br /> 'WATER QUALITY _ , r, ., <br /> strict for 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 Di <br /> made in compliance with San Joaquin ounty Ordinance No.1862 and the rules and regulations of the San Joaquin LocaHealth District. <br /> Exact Site Address } rr _. City/Town <br /> Phone c Z <br /> Owner's Name _ 3 <br /> Address -� 'rr�' City <br /> <-+.� License# �r.� Business Phone_' r� <br /> Contractor's Name Q; <br /> Contractor's Address {AlL.� - ' -- Emergency Phone = _ <br /> Is Certificate ofWorkman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK) NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL:ABANDONMENT C3 OTHER 11 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal FieldCesspool/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 /> cWDOMESTIC/PRIVATE 11 DRILLED r 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 I] OTHER Other Information <br /> E] GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <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 /> 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:"[certify that in the performance of the work forwhich this permit L <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 orsub-contracting signature certifies the fallowing:"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 /> I will 1 or a Gr Inspec ion prior to grouting and a final inspecti <br /> Signed X <br /> Title: Date: <br /> {Draw Plot Plan on Reverse ide) <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> }PHASE I Date 1 y —1 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection s inal Inspection <br /> Inspection Byeate Inspection Date <br /> ClR <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ceived By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> _. L-4 S <br /> FEE <br /> LESS' <br /> PRORATION <br /> Prus <br /> I PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> Received 6y ate -Receipt No. - Permit No. Mailed Delivered <br /> - � Issuance Date <br /> i1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />