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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign The Application — _ _11 <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferabler Revocable i <br /> ,Suspendable) ' 1 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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. V_3 i(JO r City/Town bC K)"dwV <br /> Owner's Name Phone <br /> Address 3City �i <br /> Contractor's Name License# � Business Phone47 <br /> Contractor's Address Q a-- Emergency Phone <br /> Is Certificate of Workman's Compensation Insu ante on File With SJLHD? Yes tom. No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ 39 <br /> DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I+— PUMP REPAIR❑ V`} <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �_ Sewer Lines ��.^�-'�- Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line/" Private Domestic Well Public Domestic Well d <br /> INTENDED USE ! TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> [;DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC t ❑ DRIVEN Gaugeof Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL Surface Seal Installed By: W <br /> PUMP INSTALLATION: Contractor w <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 /> R�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 for which 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 <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 _ r L . Title: Date: <br /> s <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE I - <br /> Application Accepted By ` Date - 1OU <br /> Additional Comments: <br /> Phase 11,1 Grout Inspection Phase 1 I Final Inspection <br /> hnspection By Date Inspection By ate 0 °�' <br /> Fee Is Due: ❑ ANNUALLY - El PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B^ Januar 31 <br /> - Y Y Y ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> yy AMOUNT <br /> Yrs <br /> FEE L� S R7 <br /> LESS T <br /> _ PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 W016 <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM FT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />