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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> fQR'60ICE USE: y -r�' APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) Sl <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> 1. �. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITI- - <br /> ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstall the work herein described.This application is <br /> made in compliance with San Joaquin County O�r mna.n`ce No. 1862 ane�ules and regulations of the San Joaq in LocPt Health District. <br /> Exact Site Address .�fl. �� N[ �. .+ fl City/Town <br /> Owner's Name �� Phone <br /> Address City �2 <br /> Contractor's Name icense#, Business Phone <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 ❑ RECONDITION❑ DESTRUCTION❑ V"e <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ VE <br />,. REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank S® Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line_M Private Domestic Well ;; Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ,,❑,,,,/CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 'amu S Ir1DRILLED Dia. of Well Casing *,W 0-L <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing c <br /> ❑ IRRIGATION 0 G AVEL PACK Depth of Grout Seal .9 � l <br /> ❑ CATHODIC PROTECTION I!$'ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Air <br /> ❑ GEOPHYSICAL Sprface e I In talled By: <br /> PUMP INSTALLATION: Contractor s 0 <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 /> i . <br /> Homeowner 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 forwhich this I <br /> I <br /> l permit is issued, I shall employ persons subject to workman's compensation laws of California." , <br /> i I will call for a pection prior to grouting and a final inspection. <br /> le- <br /> Signed X Title: , Date: <br /> (Draw Plot Plan on Revers Side) <br /> f f <br />€ FOR DEPARTMENT USE ONLY <br /> PHASE q <br /> Application Accepted By Date <br /> Additional Comments: <br /> ha a II Grout Inspection Phase II Final Inspection <br />! Inspection By Date Inspection By Dat�� �� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 14 PER SIE EACH ❑ January 1 &Received By January 1 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> - AMOUNT J <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _X <br /> PENALTY <br /> ! t l <br /> OTHER <br /> OTHER <br /> `751- 1i9 <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Delivered <br />�- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.-HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 ., <br />