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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> "`FOR 6'PFICE USE: APPLICATION <br /> 't (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,- , <br /> S : tt.:Z 1 <br /> ApplicationisherebymadetotheSanJoaquinLocal HealthDIstrictforapermIttocon structand/orirstaIIthe work herein described.This application is <br /> _ s. <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address M306614 City/Town _ = <br /> Owner's Name <br /> �. .a Phone <br /> Address 3,0 a 3D City , <br /> Contractor's Name :} License# t� � Business Phoney - <br /> Contractor's Address Op G T''} Emergency Pho <br /> Is Certificate ai Workman's Compensation Insurance on File With SJLHD? Yes eNo <br /> TYPE OF WORK (CHECK): NEW WELL'O 'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑' N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I <br /> REPLACEMENT❑ m ' <br /> DISTANCE TO NEAREST: Septic Tank. Sewer Lines Pit Privy W <br /> Sewage Disposal Field Cesspool/Seepage Pit Other a' <br /> Property Line: Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ .µ <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 /> L ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '" d <br /> Type of Pump H.P. ;.0 <br /> PUMP REPLACEMENT: El ate Work Done 0 <br /> PUMP REPAIR: [ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Material and Procedure �[ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 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 y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r <br /> Contractor'shiring 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 will call for a Grout Inspection prior to grouting and a final inspectlon. <br /> Signed X _ __ _ .Title:._. Date: <br /> (Draw Plot Plan on Reverse Side <br /> t <br /> FOR pkPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepte y Date <br /> Additional Commts: , <br /> Phase II Grout Inspection P ase III Fin I Inspection <br /> Inspection By f4E! Date Inspection.By Date <br /> Fee IS Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 7 &Received y July,31 <br /> REMIT <br /> EXPLANATION <br /> BASE' BILLING REMITTANCE k -AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT e <br /> 2 . <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS a <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date } Receipt No. Permit No.. Issuance Date Mailed Delivered <br /> 7.1 APPLICANT—RETURN ALL COPIES TO: I ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />