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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Faa OFFILCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> j Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in complianc with San J aquin u Ordinance No. 1862 and the r s and regulations of the San Joaquin Local Health District, <br /> Exact Site Address Q City/Town —r <br /> aye <br /> Owner's Name Phone <br /> Address a City <br /> Contractor's NameLicense# p/_OB ess Pe <br /> Contractor's Address Emergency hone '"� <br /> Is Certificate of Workman's Compens tion Insurance on File With SJLH1 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> f 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 <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 ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALur a Se I Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> CIJ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> [` Describe Material and Procedure <br /> I _ <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 for which this permit <br /> I 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 'l call for a Gro Inspection prior to grouting and a final inspe on.� �i <br /> Signed X Title: Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br /> f. <br /> FOR DEPARTMENT USE ONLY <br /> # PHASE <br /> 1 �^ <br /> Application Accepted B�:} :' -�' Date _/112 2_ <br /> Additional Comments: <br /> P as II Grout Inspectiona III Final cU?n, <br /> Inspection 13y Date Inspection <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> p REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> - A J� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> F <br /> Received by Date - Receipt No. Permit No. Iss nce Dae Mailed Delivered <br /> - NT-RETURN ALL COPIES TO: -ENVIRONMENTAL-HEALTH PERM ITISERVICES ,r,1601 E:HAZELTON AVE:;P.O.Box 2009 STOCKTON,CA 95201 <br />