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' Applications Will Be Processed When Submitted properly Completed.Be Sure To Sigel The Application. <br /> FOR OFFICE USE: .APPLICATION <br /> (For Noss-Transferable,Revocable, Suspendabie) <br /> ._ <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> " <br /> (COMPLETE IN TRIPLICATE)" <br /> WATER QUALITY' ;Q 0 2-- <br /> Appi ication is hereby made to the San Joaqui n Local Health FDistrlct for a perm it to construct and/or instal I the work herein described.This appiication is <br /> ' made in compliance with San Joa iyCounty Ordinance No.18 and the rul s and re lations of the San In Local Health District. <br /> Exact Site Addressty/Town <br /> Owner's Name Phone, b J <"7 <br /> 'Address. City <br /> Contractor's Name J'` License#k Business Phone �- <br /> Contractor's Address ROWEmergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Cr <br /> 'TYPE OF WORK (CHECK): NEW WELL DEEPEN ® RECONDITION D nFSTRUCTI0N® Q,.: <br /> 13WELL CHLORINATION WELL ABANDONMENT 13 OTHER ® PUMP INSTALLATION PUMP REPAIR® j' <br /> REPLACEMENT <br /> DISTANCE 'f0 NEAREST: Septic Tank Sewer Lines Pi 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 /> 11 IRRIGATION ® GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout <br /> 0 DISPOSAL ❑ OTHER Other information <br /> ® GEOPHYSICALSurfa a Seal Installed By: <br /> ' PUMP INSTALLATION: Contractor <br /> Type of PumpH.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 B <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 /> Hoene owner or licensed agent's signature certifies the following:"I certify that in the performance of the workforwhich 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:he performance of the work forwhich this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I will call 19r a Grout Inspection prior to grouting and a final inspection. �9 <br /> Signed X Title: � � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 0 <br /> Application Accepted By "^-�"' Date - 4v <br /> Additional Comments: <br /> Phase Bl OrotA Inspection PhasqA IIB Final li nspection 01, <br /> Inspection ByDate Inspection By 44 Date <br /> Fee is Due: ❑ ANNUALLY ® PER UNIT ❑ PER SITE ❑ EACH ❑ January 1.&Received By January 3'I ® July 1 3 Received By July 31 <br /> ' BILLING REMITTANCE $ ,EMIT <br /> BASE EXPLANATION DATE DATE ,EMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> ' LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER <br /> rl received r y Date Receipt No. Permit No. Issuance.Date Mailed Delivered <br /> �_ 2d�r�Ll �t"F—t2C rUi3R9 faLL CQ3PIES r6: rMVIROMMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,9.0.Boa 2009 STOCKTON,CA 95201 <br />