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FOR OFFICE USE: APPLICATION <br /> ��'Por Non-Transferable,Revocable,Suspendable( <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> JJJ made in compliance wit an J a in County Ordi nce No. 1862 and the rules an ulations of the San Joaquin Local Health District. <br /> Exact'Site Address City/Town <br /> 13 sal ell- <br /> 47 <br /> Owner's!Name Phone � <br /> Address - City <br /> i <br /> Contractor's Name License# Business Pone �y � <br /> Contractor's Address ni, Emergency Pho 6 -i. F <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE!OF WORK (CHECK): NEW WELL❑ . DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELDCHLORINATION ❑ WELL ABANDONMENT 11OTHER 13PUMP INSTALLATION 13PUMP REPAIR <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 /> y. DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing <br /> k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL I ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 0 <br /> PUMP <br /> 9 INSTALLATION: Contractor <br />{ I T pe of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ; State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> 1. <br /> DESTRUCTION OF WELL: 'l Well DiameterApproximate Depth <br /> !3 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 /> ordinances, state laws,''iand 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 /> ifl 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 or sub=contracting signature certifies the following:"1 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 /> Ei !I <br /> I will call for a Grout Inspection prior to grouting and a final Inspe. . on. <br /> �� s I �1.� <br /> Signed X Title: Dale- <br /> 'f II (Draw Plot Plan on everse Side) <br /> .fl <br /> I!I FOR DEPARTMENT USE ONLY <br /> PHASE 1 h <br /> € Application Accepted By max . - - Date <br /> Additional Comments: p <br /> Il Phase II Grout Inspection t Pt 111 Final I ction <br /> Inspection By Date Inspection B,, to //—/3-,� <br /> Fee Is Due: CI ANNUALLY ❑ PER UNIT- ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> { -II <br /> REMIT <br /> 'i BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> FEE ! <br /> LESS <br /> PRORATION <br /> PLUS b <br /> PENALTY <br /> :i OTHER <br /> El . <br /> a OTHER <br /> ij <br /> j Received by DateReceipt No. Permit No. Iss ante D h to - Mailed Delivered <br /> ] APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />