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ApplicationsWill Be Processed When Submitted Properly Compl ted. S e 51jp �el pplication T <br /> AOR OrFICE USE: ( APPLICAT l� b d�:.�� �U{ i <br /> Z- (For Non-Transferable, Revo �- 9t�pendable) ' <br /> ENVIRONMENTAL HE P T�7 1ga� PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I'LL <br /> r+r"tit4� <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstrlgc d/s-fwel�s�l>�tr, r� eindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regt> -L th�e}5tan Joaquin Local Health District. <br /> Exact Site Address fiV City/Town <br /> JfA <br /> Owner's Name ' - � ����—t�`.. Phone <br /> Address City <br /> Contractor's Name <br /> License# Business Phone <br /> Contractor's Address Emergency Phone " ' t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ElDESTRUCTION C�� ,,�/ <br /> WELL CHLORINATION WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION PUMP REPAIR EJ <br /> REPLACEMENT❑ <br /> 5 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ <br /> IN <br /> 9USTRIAL ❑ CABLE TOOL Dia of Well Excavation <br /> 4 OMESTIC/PRIVATE El DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑: <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL { <br /> � <br /> -Other <br /> Seal Installed 8y: � <br /> PUMP INSTALLATION: Contractor 4 <br /> TyT of Pump H P <br /> PUMP REPLACEMENT: I=I state Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <br /> N <br /> Describe Material and Procedure <br /> I <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 empioy 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: <br /> Date: <br /> (Draw t Plan on Reverse Side) _ Y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Date <br /> Additional Comments: - <br /> Phase II Grout Inspection x ase III Fin speet <br /> Inspection By Date Inspection By ate 3-/D — � <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ JUiy 1 &Received By July 31 - <br /> BILLING REMITTANCE'.- REMIT <br /> RASE- EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE � �O� <br /> LESS <br /> PRORATION <br /> PLUS <br /> .PENALTY <br /> OTHER <br /> OTHER <br /> 1 <br /> Received by Date -; Receipt No. Permit No. Iss ante D to I MaHetl Deiiveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />