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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO9*OFFICE.USE: APPLICATION <br /> ..i (For Nan-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> r ' <br /> (COMPLETE IN TRIPLICATE) WIC_(- 4g_,M15 QUALITY . : j } <br /> Application is hereby made to the San Joaquin Local Health District fora permitto constructand/or install the work.herein described.This Application is <br /> made in compli nc with San Joaquin Cgunty Ordinance No. 1862 and the rules and regulations of the San Jpaquin Local Health District. <br /> R Exact Site Add s� 1 / &-//2132 s City/Town <br /> Owner's NamePhone <br /> Address /Z `r� ��� Crl City <br /> ContractorI License#/-Z�2�z 9' Business Phone g� 3-���� • s <br /> Contractor's Address •7y41Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - f <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 0`4 Cesspool/Seepage Pit Other t 'j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation II <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY 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 t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <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 forwhich this permit <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Y <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By �f - Date <br /> i. Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final t peclion <br /> Inspection By Date Inspection Bye Date <br /> f <br />� 1 <br /> e Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 ' <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> i FEE <br /> LESS <br /> PRORATION <br /> PLUS 4 - <br /> PENALTY - <br /> t OTHER <br /> I OTHER <br /> Received 6y�.,��- Date Receipt No. Permit No. Issuance Dale Mailed Delivered _ <br /> t <br /> APPLICANT—RETURN"ALL,COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />