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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign,rneApprro—Z19wr111 <br /> L_OFFISE: APPLICATION -� <br /> (Far Non-Transferable, Revocable, Suspendable) PUMP&WE=LL r t f <br /> ENVIRONMENTAL HEALTH PERMIT J <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and/or install the work herein described.This application is 1 <br /> made in compliance with San Joaquin Coi Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> �� OQ .�.s�, , City/Town <br /> Exact Site Address , <br /> Phone <br /> �9 <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's Name License# 3, 7 / Business Phone <br /> Emergency Phone <br /> Contractor's Address No I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> ii <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> { <br /> INTENDED USE TYPE OF-WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> �ti� ' Dia-of'Well_Excavation- u �' <br /> DOMESTIC/PRIVATE <br /> 11 DRILLED Dia. of Well Casing § <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ( _� <br /> i <br /> El DISPOSAL ❑ OTHER Other Information <br /> Surface Seal, Installed By <br /> 11 GEOPHYSICAL <br /> I PUMP INSTALLATION: Contractor H P <br /> Type of Pump S <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 13State Work Done <br /> j <br /> j DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 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 perjformance 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 a Grout inspection prior to grouting and a final inspection. <br /> Title: _ Date: 7 g <br /> Signed <br /> (Draw Plot Plan on Reverse Side) <br /> --:3�FOR DEPARTMENT USE ONLY <br /> s-W:-=.� .�r•. _. <br /> PHASE I Dake 1 <br /> € Application Accepted By .'" ' "`F`E <br /> Additional Comments: {{ a <br /> Phase ti Grout Inspection1 ^' Ease III Final Inspection j 1 Q <br /> F Inspection By v to <br /> Inspection By Date <br /> t ' <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ate❑ PER SITE'"' -❑ EACH ❑ January 1 &Received By anuary 31' ❑ J Received By July 31 <br /> f w REMIT <br /> F BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t <br /> FEE <br /> LESS <br /> PRORATION --------- <br /> PLUS <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> r <br /> j- OTHER ] <br /> 1 *ter <br /> Received by. <br /> Date Receipt No. f Permit No. Issuance Date Mailed Delivered <br /> L APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1fi01 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />