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` Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> i FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> k PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> x <br /> (COMPLETE 1N TRIPLICATE) WATER QUALITY =. ; <br /> r Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This applicatio iS <br /> made in compliance with San Joaqptn County�O d}'na�n e No,1&62 a d the ruses and regulat1 of th San Joa ut ocai_HeaJlth Di trict. d <br /> Exact Site Address —07L75 /�/ <br /> Owner's Name '¢ Phone ✓ :.� <br /> Address City-- C } <br /> i Contractor's Name ` License# �/� Business Phone <br /> Conttactor's Address 1 — Emergency Phones <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No <br /> TYPF OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ /7 I <br /> DISTANCE TO NEAREST: Septic Tank _�/c Sewer Lines Pit Privy <br /> r � <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 /> f P4 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Pff GRAVEL PACK Depth of Grout Seal 6 <br /> ❑ CATHODIC PROTECTION lal ROTARY Type of Grout ' V <br /> ❑ DISPOSAL ❑ OTHER Other Information ��T <br /> © GEOPHYSICAL Surface Seal Installed By: - <br /> PUMP INSTALLATION: Contractor <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 Q <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." f1 <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 /> I will all for a Groui Insp on prior to routing and a incl inspectign. n <br /> Signed X Date: �J <br /> raw Plot Plan on Reverse Side) <br /> FO EP MENT U ONLY <br /> PHASE I � G _ Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase Grout Inspection as nal inspection Q� <br /> Inspection ByDate a Inspection By Date 5 v� <br /> i Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2 G-- yQ9G <br /> Received by Date Receipt No.. 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 />