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6 ca[i'6n vWm Be Processed�I Submitted Properly Completed. Be Sure To Sign The Application. tj <br /> FOR OFFICE USE: SEP iAPPLICATION <br /> SEP $ <br /> For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> }� L�}�IJ�RONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATEI-IEkLTH DISTRICT WATER QUALITY <br /> Application is hereby madeto 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 quin I_pcal Health District. <br /> Exact Site Address - City/Town <br /> ' p d rL"' "tis /�-C► A/ L Z Phone <br /> Owner's Name !1J <br /> �. ,,.,:,,: :w City.A <br /> Address <br /> Contractor's Name \ License lD Busine s Phone�� 6� 2�� f <br /> Contractor's Address ,>'IAn&A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on file With SJLHD? Yes ._ No - ;[ <br /> TYPE OF WORK (CHECK):- NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑� — <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® Ov <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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL -❑ CABLE TOOL Dia. of Well Excavation - <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC !'❑ DRIVEN i Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY + Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. O <br /> PUMP REPLACEMENT: a❑ State Work Done <br /> PUMP REPAIR: ® State Work Done A I- 1p, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> iDescribe 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 forwhich 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 for which this <br /> permit is issued, I all employ persons subject to workman's compensation I ws of California." <br /> I W. I to a t pection prior to grouting and a final inspectio <br /> Signed X Title: Date: � � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I VII Date w` <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection # VP; s'll Final Inspectio <br /> Inspection By Date Inspection By Date - � <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ FACH' ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE. EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT. <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received ay Date Receipt-Nv.- -Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />