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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appiicallon. A <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 Joaquin County Ordinance No. 1862 an rules and regulations of the San Joaq in Loc I ¢allth stric . <br /> kt)ti L t <br /> Exact Site Address City/Town <br /> Owner's Name O .4 Phone Q <br /> City <br /> Address � - <br /> Contractor's Name <br /> ense# :? Business-Phone <br /> Contractor's Address <br /> + Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With 5JLHD? Yes�_ _ <br /> TYPE OF WORK {CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank . Q. — <br /> Sewage DisposalFie ld � Cesspool/S7page Pit <br /> Property Line's, —r Private Domestic Well�"fPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑-CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL t ov <br />. � <br /> DOMESTIC/PRIVATE <br /> ' ❑ DRILLED Dia. of Well Casino- <br /> DOMESTIC/PUBLIC " ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �j&ROTARY Type of Grout <br />`I ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL '�`��ox Gv�lt< /q C•lit�s�_ ���,�^� d �,��rc -.� CA <br /> k PUMP INSTALLATION: Contractor I <br /> L., <br /> Type of Pump H'P• <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: if Q <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. j <br /> Homeowner 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-cont ctin signature certifies the following:"I certify that in the performance of the work for which this <br /> j permit is issued, I shall mpic pe ns subject to workman's compensation laws of California." <br /> I <br /> I wiil l for a ut pec n rior to grouting and a final inspection. <br /> Signed X <br /> Title: .. 74- Date: <br /> { <br /> 7 (Draw Plot Plan on Revers ide) - <br /> ( FOA PARTMENT USE ONLY <br /> PHASE I Date X, <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection - se til Final Inspection 7-1 <br /> Inspection B <br /> Date Inspection By . Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ER SITE El EACH - ❑ 'January 1 8 Received B January 31 ❑ July 1 &ReceiveR�EB�IT 31 <br /> ? •.$ BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> � d <br /> OTHER <br /> Received by <br /> Date Receipt No Permit No. Issuanc [ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />