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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&WE=LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with_.$ali JoaquinWOr 'naZnceo. 24annd the r es a d regulations of the San uin o Health District. <br /> Exact Site AddressLS /`� City/Town1 Owner's Name Phone �9-9/—7�Address City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER UMP IN TAL,LATION11AI��RE� 1 <br /> Net <br /> REPLACEMENT 11 I I elyKa� PV4L (�J(�' <br /> DISTANCE TO NEAREST: Septic Tank v + Pewer Lines Q Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other a� <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE C1 DRILLED Dia. of Well Casing <br /> Al-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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> V"La 1 G Descr a Mater' I d Procedure t <br /> B� <br /> I hereby certify that I have prepared this applicatiorilkind that the work will be done in Kccordance wiitA W a ounwnty <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> Application Accepted By !/(/ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a fl Final Inspection G <br /> Inspection By Date Inspection By � >ate U A D <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Lived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLiNG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> jFEE <br /> [ft__::777I <br /> pQ.�c�r�„`'-''}� 5�� r Date Receipt No. Permit No. Iss ante to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />