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OTHER _ Other Information <br />' Surface Seal Installed By: <br />Contractor <br />Type of Pump ex, <br />0 State Work Done <br /> <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />DOMESTIC/PUBLIC <br /> 0 <br />IRRIGATION <br />0 CATHODIC PROTECTION <br />APPLICATION <br />(For Non-Transferabie, Revocable, Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign me Application. <br />PUMP & WELL <br />(COMPLETE IN TRIPLICATE) <br />WATER QUALITY <br />Application is hereby made to the San Joaquin,Local Health District for a permit to construct and/or install the work herein described. This application is <br />made in compliance with San Joaquin Coun -Ordinance No. 1_,2 and the rut:and regulations of the San Joaquin Local Health District. <br />Exact Site Address <br />Sewer Lines Pit Privy <br />Owner's Name <br />Address / <br />Contractor's Name <br />Contractor's Address <br />Is Certificate of Workman's Compen <br />TYPE OF WORK (CHECK): <br />WELL CHLORINATION 0 <br />REPLACEMENT 0 <br />DISTANCE TO NEAREST: <br />3/k ':City/Town 7# <br />Septic Tank . <br />Sewage Disposal Field <br />Property Line Private Domestic Well <br />TYPE OF WELL <br />CABLE TOOL <br />DRILLED <br />DRIVEN <br />GRAVEL PACK <br />ROTARY <br />...: <br />......- „iiiiiimprom City 7:: <br />License #122,1 40 Bus ass Rho <br /> <br />: . . .... - IF <br />5 Emergency Phone -- <br />a t i o n Insurance on File With SJLHD? Yes X No <br />NEW WEL DEEPEN 0 RECONDITION 0 DESTRUCTION Ci <br />WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION,.. PUMP REPAIR 0 <br /> Cesspool/Seepage Pit Other <br />Public Domestic Well <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Phone P? 7103 <br />PUMP REPAIR: State Work Done • <br />DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />Describe Material and Procedure <br />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 />I will call for a grout Inspection prl r to grouting and a final inspec n. <br />Signed X Title: <br />(Draw Plot Plan on Reverse Side) <br />Date: 20 0 tX) <br />Jar,uary 1 & Received By January 31 July 1 & Received By July 3? <br />Receipt No <br />C)Cd? <br />" No.- - <br />FOR DEPARTMENT USE ONLY <br />PHASE <br />Application Accepted By <br />Additional Comments: <br />Phase II Grout Inspection <br />Inspection By Date Inspection By <br />Ph I Final Inspection <br />Date _2/A <br />Fee Is Due: Li ANNUALLY _ .... _ <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED _ <br />AMOUNT BASE • <br />4 <br />EXPLANATION <br />BILLING <br />DATE <br />FEE 14 5". <br />LESS <br />PRORATION <br />I <br />i PLUS <br />PENALTY <br />OTHER <br />OTHER . <br />, -- <br /> Date <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />ar--0 <br />Issuance Date .kiteiied • De ted <br />1601 E. HAZELTON AVE:, P.O. Box 2009 STOCKTON, CA 95201 Date Received by <br />APPLICANT RETURN ALL COPIES TO: <br />DISPOSAL <br />GEOPHYSICAL <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />FOR OFFICE USE '