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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) <br /> PUMP&WIrLI: , <br /> IN ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work.herein described.This application is <br /> made in compliance with Sanoaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq 'n cal Health District. s <br /> Exact Site Address City/Town — <br /> Owner's Name Phone_ <br /> Address City / <br /> Contractor's Name License# Business Phone / a <br /> Contractor's Address Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No �] <br /> TYPE OF WORK (CHECK): NEW WELL E. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �T <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank I Sewer tines Q Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line �7t Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> J4 DOMESTIC/PRIVATE ® DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C_ <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal SA <br /> t <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r" <br /> r• <br /> PUMP INSTALLATION: Contractor <br /> t <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 f <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 /> 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:"1 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 /> 4 Contractor's hiring or sub-contracting signature certifies the fallowing:"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 /> I will call for Grout Inspection prior to grouting and a final inspection. h + <br /> Signed X �x Oiler Title: ��1► Uv c-- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> Application Accepted B Date <br /> Additional Comments: <br /> ase II Grout Inspection P �se IIIn Final Inspection, <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BSLLING REMITTANCE $ AMOUNT DUE CHECKED <br /> + DATE DATE REMITTEE) AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> + OTHER <br /> k . <br /> k OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 952 . J <br /> d <br />