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Applications Will Be Processed When Submitted Propeny ti.ompre-rv. ww��•� -•�•• �r <br /> FOR OFFICE USE: APPLICATION <br /> _.. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 Joaq in Co ty Ordinan o. 18Q2 an the u e nd re u1 v of the San Joagu�ca Health District. <br /> lty/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name <br /> City <br /> Address �•�j ,. � � <br /> Contractor's Name License#�_ [mousiness Phone <br /> Emergency Phone � _ 'r.1—i <br /> Contractor's Address . No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> - rrx nrrunzn� F1 in+ ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> I <br /> ContractoilQY1C ' + '1 ll�t° Address d, 30,, 0 LiNjell, License No" 77 qZ3 Phone "3!&5 <br /> Sewage Disposal Field Cesspoo eepage P11vrilcr <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 If Surfa a 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance w'1ti Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1i0- 4 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhichthis 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 call f a Grout Inspection prior grout' g and inal inspection. <br /> Signed X Title: <br /> i Date: �` <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPART72- <br /> SE ONLY <br /> PHASE 1 p G,� 90 <br /> Application Accepted By_9z="_2 Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection PI ase III Final lnsp tion _ l <br /> Inspection By Date Inspection By ate <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT IS PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EXPLANATION J31LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> G ✓ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />