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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> } FOR1!TFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendabler PUMP&WELL <br /> ENVIRONMENTAL—HEALTH PERMIT <br /> lEsQUALITY <br /> (COMPLETE IN TRIPLICATE) J,t�,E,_ W fR <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/o'r`instali the work herein described.This application is <br /> made in compliance witSan Joaqui Unty rdinance No.1862 and the rules and r'rgu ti ns of the San Joaquin Local Heal District. <br /> i Exact Site Address " ` t' .City/Town <br /> Owner's Name = PhoneS� <br /> Address a City - - <br /> Contractor's Name ,a: License# r� �1'�,3 Business Phone <br /> Contractor's Address Emergency Phone e , <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes X — No <br /> TYPE OF WORK (CHECKJ: NEW WELL. DEEPEN 11RECONDITION❑ DESTRUCt10N❑ <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 /> l INTENDED USE TYPE OF WELL. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well.Excavation9 . . / + <br /> DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing h Pro' <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4 GLJ <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal �} <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information' <br /> ❑ GEOPHYSICAL . _ w _ Y Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: s State Work,Done. - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> I 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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to,workman's compensation laws of California." <br /> E <br /> I will all for a Grout lnspe n prior to grouting and a final Inspect' <br /> Signed X �: Date: ev <br /> (D6u Plot Plan on Reverse Side) <br /> FOR DEPARTMENT E ONLY <br /> PHASE I <br /> Application Accepted By _ Date <br /> Additional Comments: <br /> Ph R Grout Inspection , 22 Phase 111 Final Inspection <br /> .inspection By C Date J Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -- REMIT <br /> t BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4-3 <br /> LESS <br /> PRORATION 1. _ <br /> PLUS <br /> PENALTY <br /> PENALTY <br /> OTHER , <br /> ' f <br /> OTHER <br /> i Received by.-.` ate - _ eceip No.. Permit No. Issuarice Date - Mailed- Delivered <br /> 71APPLICANT—RETURN ALL COPIES TO: i ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2909 STOCKTON,CA 95201 <br /> r <br />