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_ppoa.auvna Twill vc vwwaaeu Twigen auvunueu rwpeny ik.umpleteu. oe aure 1 o a1gr1 i ne Appiiin. <br /> FOR OFFICE USE: APPLICATION <br /> C,3 !/0 j .J <br /> (For Non-Transferable, Revocable, Suspendable) 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 /> made in compliance with San,n�voa uin `Cont dinance No. 186 and the rules and regulations of the San Jo a n oW Health District. <br /> Exact Site Address &A J !V y +��i __ ` fo g City/Town �2°` <br /> ,Owner's Name Phone <br /> Address S 3 e &#t Cly <br /> Contractor's Name License# LJ Business Phone 6 2 - G 7 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes � No d <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR <br /> REPLACEMENT❑ Y <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 Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout n <br /> �.❑ DISPOSAL ❑ OTHER Other Information p� <br /> ❑ GEOPHYSICAL urface Seal Installe y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump stj�7 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 with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 forwhich this ` <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I Vol call for a Grout Ins ecti n for to rout) g andfinal inspection. <br /> Signed itle: `1 i&J Date: A f <br /> ( raw Plo an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspectionh e III Final Inspection �` 6 <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received y anuary 31 ��❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> 'r AMOUNT <br /> FEE 5 �� <br /> LESS <br /> _ PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a. <br /> OTHER <br /> b 039 7/a1 IN0 <br /> _ Received by Date Receipt No. Permit No. lissuanc6 Gate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CP <br />