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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application'. ~— <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) I� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein <br /> made in compliaaiL <br /> in Co t rdinance o. 186 an he rules and regulations of the San J in Loca cHbaltlhThis <br /> Distacplication is <br /> L li <br /> Exact Site Addr <br /> City/Town <br /> Owner's Name <br /> Address Phone <br /> i City i <br /> Contractor's Name , <br /> license Business Phone 4: <br /> i Contractor's Address 11 Emergency Phone iM <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ No <br /> l RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION.❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ElPUMP REPAIR!❑ <br /> REPLACEMENT❑ II r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> 11 <br /> Pit Privy I r <br /> Sewage Disposal Field Cesspool/Seepage Pitj <br /> Other <br /> Property Line Private Domestic Well Public Domestic Well I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLI� <br /> ❑ Dia. of Well Excavation <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing I� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal II_ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11 DISPOSAL Type of Grout IM <br /> ❑ OTHER Other Information IM <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: IM til <br /> PUMP INSTALLATION: Contractor I� <br /> Type of Pump H.P. IM <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I` <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> A proximate Depth <br /> D scribe Ma rial and Procedure )f <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, apd rules and regulations of the San Joaquin Local Health District. `I <br /> Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which thus permit <br /> is issued, I shall not employ an .� <br /> p y y person in such manner as to become subject to workman's compensation laws of Cal fornia." Q <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 /> 11. <br /> I all or G ui Inspection prior to grouting and a final inspection. <br /> Signed X II `�IPC�d7/ ` <br /> itie: II �Q <br /> I; (Draw Plot Plan on Revere Side) Date: <br /> Il <br /> PHASE ] <br /> I FOR DEPARTMENT USE ONLY I <br /> Application Accepted By— .'I r iV p ( <br /> Additional Comments: 11 Dates d <br /> Phase II Grout Inspection <br /> Inspection By <br /> h e III Final Inspection <br /> I� <br /> li Dake Inspection By a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EAGH <br /> ❑ January 1 &Received By January'31 ❑ July 1 &Received By July 31 <br /> BASE I EXPLANATION MLLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE y <br /> AMOUNT <br /> 3 <br /> LESS 7i 1443 <br /> PRORATION I�I <br /> PLUS <br /> PENALTY ill Ir <br /> OTHER <br /> OTHER <br /> Received by Date II Receipt No emit No ^� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ssuan a Date Mailed Delivered,', .# <br /> 1601 E.HAZELTON AVE.,PO.Box 2009 STOCKTON',CA 9520' <br />