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tlsE: HprNIGd11onu WWII, DU rfavus�ea lynen Ou'Jmniea F70Perly '"mpleleu. Oe .lure 1 o algn i ne Hpplicailon, <br /> . APPLICATION <br /> _ (For Non-Transferable, Revocable, Suspendable) s <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL r <br /> :.ETE IN TRIPLICATE) WATER QUALITY <br /> F ,n is hereby made to the San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is IN <br /> r. compliance with San Joaquin County QrOinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> , Ex«.t.`.. Address S �',_ ��, � City/Town -n;c;row i 6 _ <br /> Own, � "dame �. t`C% '-4 �`�S d� — S 5 <br /> Phone 4 ( �� <br /> Address S_y n L <br /> yy� City ��©fl_ Y�U' <br /> Contractor's Name i'I l License# t� Business Phone ��7Z? <br /> Contractor's Address . —� Emergency Phone "T to I y ' —4. <br /> Is Certificate of Workman's Compensation Insurance on Pile With SJLHD? Yes_- — ,No <br /> rTYPE OF WORK (CHECK): NEW WELL 11DEEPEN ElRECONDITION 11DESTRUCTIONWELL CHLORINATION 13WELL ABANDONMENT 13OTHER ElPUMP INSTALLATION 11PUMP REPAIRS <br /> REPLACEMENT❑ <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 <br /> 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 Instafled By:, <br /> PUMP INSTALLATION: Gontractot- <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r <br /> PUMP REPAIR: ElState Work DoneDESTRUCTION OF WELL: Well Diameter Approximate Depth Describe Material and Procedure <br /> I hereby certify that I have prepared this app3ication 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:"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 /> 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 ersons ubject to workman's compensation laws of California." <br /> I c I for a Grout Ins p n prio o grou ' and a final inspection. <br /> Signed X Title: <br /> E,a Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By "' Date /.2- 3- 7 <br /> Additional Comments: i <br /> Phase II Grout Inspection final Inspectionq <br /> Inspection By Date Inspection By Date PP—/P— <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ly 31 <br /> REMIT <br /> BASE .EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> D TE PATE REMITTED AMOUNT <br /> I: <br /> FEE <br /> " LESS <br /> + PRORATIONPLUS i <br /> PENALTY - -"-jam/ �f�!�: v <br /> L <br /> >1 <br /> Fi OTHER <br /> OTHER <br /> �. 77 <br /> Received by Dale Receip!No, Permit No issuance Date Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1141 E.HAZELTON AVE.,P.O.9or 2005 STOCKTON,CA 95201 <br />