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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 7 <br /> (For Non-Transferable,'Rev6cable Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY` . <br /> A, 3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with S n Joaquin Co Oxdina a No. 1862 nd the rules and regulations of the San J_ pain Local Health District. <br /> Exact Site Address rr " City/Town" <br /> `.° I A ; <br /> Owner's Name '} ,0„'. Phone?V2 <br /> - - i <br /> Address r.. .. �� :.. : 'City <br /> Contractor's Name t' d"License B <br /> Contractor's Address '' Emergency Ph ne : <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_-_ No G-1 <br /> TYPE OF WORK (CHECK))i` `NEW WELL'❑--' DEEPEN^1:1 -- RECOINIDIT�ON❑ DESTRUCTION 0' y/ j <br /> IRICI 4 f'h LJI F'1[]IIIAT.IlIAI <br /> 171 4AIC1 ! AL]A AI Rf1Al\ACI�IT 1 1 11TLJCO_A. 1_��..D1 MAD IAICTAI I ATI(l Al I�l DI MAD NMDA ID <br /> �w -� .....-�+..��wr-�....:..www..wwwwNw...w+��....I --. rr• : �r .s..r.++ :.. .-� - v- <br /> Contractor <br /> �Itf Address <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic.Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL j <br /> ❑ NOUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC a <br /> � ❑ DRIVEN Gauge of Casing I <br /> 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> z Type of Pump - 1 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done a <br /> PUMP REPAIR: State Work bane 11!_eme P6 <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth n <br /> 0. Describe Material and Procedure <br /> I <br /> I hereby certify that I have prepared tliis 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. 9 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 4 <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 7 <br /> ' permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will call for a Grout Inspection prior to grouting and.a final inspects <br /> Signed X_.. Title:. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By # Date L.`._ _ LZ <br /> Additional Comments: <br /> Phase II Grout Inspection P al r> ectlon <br /> Inspection By.. Date Inspectioeceiv6d <br /> Date w 7 rY <br /> Fee Is Due: 13 ANNUALLY El PER UNIT!,_ '❑ PER SITE ❑ EACH -1:11 January 1 By January 31 ❑ July 1 &Received By July 31 <br /> ' <br /> BILLING .,,REMITTANCE $ REMIT <br /> s»—,. <br /> BASE - EXPLANATION `• AMOUNT DUE CHECKED <br /> DATE DATE :REMITTED <br /> AMOUNT <br /> �s <br /> ` <br /> FEE t4 j. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l <br /> �.- <br /> Receivedby �� _ Date _ Receipt.Na.- - - Permit.No,. - l yuan a 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 />