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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Cs�—� <br /> ' APPLICATJON �' '7 <br /> FOR C;�F,�ICF�,USE:� r� ;,;�� <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> `ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described.This application is <br /> made in compiianc@ wi h San Joaquin County Ordinance No. 1862 and the rules and ulations of the San Joaquin Local Health District. <br /> Exact Site Address(3J e City/ own S G ' <br /> Owner's Name 0 15A/t MS' Phone — 9-419, 31 <br /> Address to e City C 7w <br /> Contractor's Nameuivivedur License#2(05'74/ Business Phone <br /> Contractor's Address 11-3 Nb cdili/� AZ, Emergency Phone a � 1 Q <br /> Is Certificate of Workman's Compensation Insur nce on File With SJLHD? Yes &_� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑:, DESTRUCTION❑ {� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19-- PUMP REPAIR❑ �+ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _, ! I Pit Privy <br /> Sewage Disposal Field 5e9 I Cesspool/Seepage Pit Other <br /> Property Line V f- Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> JX 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 /> El DISPOSAL <br /> ❑ OTHER Other Information .l <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump C� �'��I F �Y! H.P. �— <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certities 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:1 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 /> , <br /> I will call for a Grout Inspection prio to grouting and a final inspec ' n <br />` Signed X <br /> Title: Date: 0.4 <br /> (Draw Plot Plan on erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By — Date <br /> Additional Comments: Zy <br /> Phase II Grout Inspection Ph se III F071 Inspection <br /> Inspection By /C? Date Inspection By Date ! �� <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> �! sa <br /> FEE <br /> LESS <br /> PRORATION <br /> j PLUS <br /> PENALTY <br /> OTHER x <br /> OTHER <br /> Received by Date Receipt No. Permit No. is4uancb Date Mailed Delivered <br /> L- APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES i' 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />