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W plications Will B Processed When Submitted Properly Completed.Be Sure To Sign The Application. r <br /> FOR OFFICE USE: APPLICATION f <br /> - ransterabie Revocabte, Sus endable) PLUMP&WELL <br /> L�af�n T � P <br /> - E -VIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> OMPLETE IN TRIPLICATE) <br /> (CY <br /> trictforapermittoconstructand/orinstallthework herein described.This application is <br /> Application is hereby made tothe San Joaquin Local Health Dis <br /> made in compliance w't a uinnt r finance N�1862andthe ules and regulations of the Sa�J In Local Health District. <br /> Exact Site Address f City/Town �� <br /> Owner's Name Phone <br /> City <br /> Address <br /> Contractor's Name License <br /> Business Phone 1 <br /> Contractor's Address mergency Phone <br /> f 16 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLH ? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 RECONDITION 11DESTRUCTION❑/ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank <br /> - Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line t Private Domestic Well Public Domestic Well , <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ! <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 /> 11DISPOSAL ❑ OTHER Other Information <br />- ❑ GEOPHYSICAL Surface eal Installed By: <br /> PUMP INSTALLATION: Contractor, <br /> T e of Pump H.P. <br /> PUMP REPLACEMENT: State Work Don <br /> PUMP--REPAIR: - ..1. State Work Done 4 <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perm t <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca r Grout Inspection pr' grouting and a fin nspection, r_r r. of <br /> Signed X : Date: <br />' r Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 11 <br />` -PHASE I Q t Date — <br /> Application Accepted By--- <br /> Additional Comments: <br /> Phase II Grout Inspection hese I Inspection p <br /> Inspection By Date <br /> Inspection By ate [� <br /> Fee is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July l &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Ll <br /> LESS' <br /> PERORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER l <br /> sem}' <br /> °Y Received by - Date - Receipt No. Permit No. - //`l is ance to Zailed """--'Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 'i601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95261 <br />