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Applications Will Be Processed When Submitted Properly Comp eeSure osign netappIPq��+r• f FOR OFFICE USE: APPLICATION 00T_ 1 79 (For Nnn-T�absferable,Revocable,Suspendable) PUMP&WELL R ENVIRONMENTAL HEALTH APIMITOAQUIN LOCAL l WATER QUALITY HEALTH DISTRICT (COMPLETE IN TRIPLICATE) District fora permit to construct and/or install the work herein described.This applicatign is-0 Application is hereby madeto the San Joaquin Local Health made in compliance with San Joaq 'n C nay Ordinance No. 18 2 a d the rules and regulations of the San a uin Local Health District. y Exact Site Address City/Town Owner's Name _ Phone — City Address _ Contractor's Name License#�� Business Phone Contractor's Address Emergency Phone --3 No Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION 11DESTRUCTION❑ PUMP REPAIR❑ WELL CHLORINATION"❑ WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION 1 REPLACEMENT❑ — DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ ' Sewage Di ;posal_Field' F Cesspool/Seepage Pit ��`f7 Other Property Lined�:Private'•Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL !11 ` ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation — DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 13DOMESTIC/PUBLIC E] DRIVEN Gauge�df Casing""' .� 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - 11 DISPOSAL ❑ OTHER _ Other Information ❑ GEOPHYSICAL -� Surface Seal Installed By: PUMP INSTALLATION: Contractor i �^ Type of Pump f' � " H.P. PUMP REPLACEMENT: ❑ State Work Done I ( f r c PUMP REPAIR: ❑ State Work Done t i DESTRUCTION OF WELL: Well Diameter -- Approximate Depth Describe"Material and Procedure - I hereby certify that I have prepared this-application and that the work 'ill-be done in accordance with San Joaquin County ordinances, state laws, and rules and regulations of the San.Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." '$ Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performs e of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." c I will call for a Grout Inspection prior to grouting and afinal-inspection.. ' - " — Title: i Date: Signed X j (Draw Plot Plan on Reverse Side) s OR YIEPARTMNT USE ONLY f PHASE IDate I2 Application Accepted By � I i Additional Comments: , Pha e I Grout Inspection . ,,. Ph a III Final Inspection�4 FInspection By Date Inspection By Date a ❑ Januar 1 &Received By January 31 ❑ JuVy 1 &Received By July 31 Fee IS Due: ❑ ANNUALLY El UNIT PER SITE ❑ EACH y REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT +.C_ FEE l 6 _ LESS _ .. °r F PRORATION PLUS PENALTY OTHER OTHER � k 5Q ti Issuance Date Mailed :. Delivered ', Received by Date Receipt tSo. Permit No. APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMITlSERY10E5 1601 E.HAZELTON AVE.,P.O.box 2009 5TOCKTON,CA 45201 ��_.