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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ` = <br /> 'Poli uFFICE_US E: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) f <br /> ENVIRONMENTAL HE;,ad_-TH PERMIT PUMP&WELL W <br /> (COMPLETE IN TRIPLICATE) WATER QbALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made.in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Co,,2 z��.v City/Town <br /> 1 <br /> Owner's Name Phone <br /> Address City ; <br /> Contractor's Name License Business Phone / I <br /> k <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 0 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ '6 rf Sewer Lines SO r Pit Privy <br /> ! <br /> Sewage Disposal Field ZO t4 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 62) I Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Weil Excavatio A, r j <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casin u <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `2 .g ,FI_IQlalpFl� <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 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <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 forwhich 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-contracting signature certifies the following:"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 II for a out nspe i? 'prior to grouting and a final inspection. <br /> kor <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse6ide) <br /> s <br /> FO PARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B/1- <br /> Additional <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due. ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 � <br /> BILLING - REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> ... <br /> LESS a <br /> PRORAT$ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 777�q <br /> �l <br /> Received by Date "Receipt No. Permit No l suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />