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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (for Non-Transferable, Revocable;Suspendable) PUMP St WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY f -1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein_described.This applicationis <br /> made in compliance with San Joaquin County Or inance No. 1862 and the rules and regulations of the San Joaquin Local Health District. } <br /> Exact Site Address ' W, City/Town - .�P- �- <br /> :E <br /> Owner's Name t' _ Phone <br /> Address i r.S ;�s City <br /> Contractor's Name QLD � _'bcen_se#,,.;Ld3E�t Business Phoneme <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ti <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <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 /> i Property Line - Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I ,❑., INDTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> YXDOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Cl GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -_',---T- *- �- Surface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor <br /> ... <br /> Type of Pump 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 /> 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 rule s,and regulations of the San Joaquin-Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I is issued, i shall not employ any person in such manner as to become subject'to workman's compensation laws of California." <br /> f 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 employ persons subject to workman's compensation laws of California." <br /> C rout inspe ion prior to grouting and finale Inspection. <br /> Signed Title: Date: Gp�- <br /> (Draw Plot Plan on Reverse Side) <br /> f j FOR DEPARTMENT USE ONLY <br /> i' PRASE I <br /> I Application Accepted By Date <br /> - <br /> Additional Comments: i <br /> Phase 11 Grout Inspection Ph Inal Inspection,/, .IP,_ <br /> - Inspection By - -A Date � Inspection By Date <br /> F Fee-Is Due: ❑ ANNUALLY ❑.PER UNIT 0 PER SITE C1 EACH ❑ January 1 &'Receided 8y January 31 ❑ July 1 &Received By July 31 <br /> ' - REMIT - <br /> BASE EXPLANATION BILLING —REMITTANCE _ $ 'AMOUNT DUE - CHECKED <br /> (� DATE DATE REMITTED AMOUNT <br /> t <br /> FEE <br /> LESS --r: <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> J' OTHER - - - <br /> t <br /> OTHER .. <br /> , t <br /> Received by - -Date — Receipt No. - Permit-No - - Issuande Date Mailed Delivered - <br /> i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 1 r <br />