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' Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. �. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ._ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ��O(. I,r1, ,LFI 6;ZL,,,V !Z WATER QUALITY' OZ5—ate-0 2,— <br /> Application is hereby madetot6e San Joaquin Local Health District fora permit toconstructand/orinstallthe work herein described.This application is <br /> ' made in compliance with San Jolla i ounty Ordinance No. 18 and the rul s and re lations of the San oaq in Local Health District. <br /> Exact Site Address ity/Town/_p�`J�/g <br /> Owner's Name Phone b f �7-7J <br /> ' Address_ City , <br /> Contractor's Name }"f License#=MV Business Phone <br /> Contractor's Address'Arm Emergency Phone <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 /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP 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 /> ❑ 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' Surfa a Seal Installed By:PUMP INSTALLATION: Contractor - <br /> 77 <br /> Type of Pump H.P. a <br /> PUMP REPLACEMENT: ❑ State Work Done j <br /> ' PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I b <br /> I hereby certify that 1 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 forwhich 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 persons subject to workman's compensation laws of California." <br /> I will call t r a Grout Inspection prior to grouting and a final inspection, <br /> ' Signed X .. Title: al4 _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASEI {�FOR DEPARTMENT USE ONLY <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection, <br /> Inspection Byi— � Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I.&Received By January 31 /• ❑ July 1&Received By July 31 <br /> ' BILLING REMITTANCE5 REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ,/� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> �^ P <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bon 2009 STOCKTON,CA 96201 <br />