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ti <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - - WATER QUALITY <br /> (COMPLETE IN IPLICATE)' � S �4Ck_, �. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance h S n Joaqun unty rdinan a No. 1862 and the rules and re9plations of the San Joaquin Local Health District. ! <br /> Exact Site AddresS� .iAi ity/Town <br /> �� <br /> 50 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Al License# f/�- Businesshone <br /> ��� _ Emergency Pyrone } <br /> Contractor's Address„�f'���� g <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .. No l <br /> TYPE OF WORK (CHECK): NEW WELL Ad DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ( Viewer Lines � Pit Privy r” N. <br /> Sewage Disposal Field Cesspool/�eepag e Pit r""1 Other "�— <br /> Property Liner_ Private Domestic Well -fir Public Domestic Well <br /> INTENDED USE TYPE OF WELL 4 <br /> i ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation I <br /> 11DOMESTIC/PRIVATE '❑\\DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> - <br /> ❑ CATHODIC PROTECTION ElROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 /> 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:"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-contras ingsignature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permit is issued, I shall employ rsons subject to workman's compensation laws of California." <br /> I r ro s ti prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> I (Draw Plot Plan on Reverse 'de) <br /> FOR DEPARTME T USE ONLY - <br /> I PHASE q <br /> Application Accepted By-- d Date <br /> Additional Comments: - <br /> i Phase 11 Grout Inspection I Final lnspection ' <br /> Inspection By <br /> Date Inspection Date � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Ldp PEn SITE ❑ EACH ❑ January 1 eceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION a <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1' Received by Data Receipt No. Permit No. Is uan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />