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Application.. <br /> Applications Will Be Processed When Submitted Property Completed. Be Sure ToSignThe <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> {WATER DUALITY _ <br /> (COMPLETE IN TRIPLICATE) <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 /> 1862 and-the rules and.regulations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance No. <br /> Exact Site Address <br /> o p City/Town <br /> Phone' <br /> Owner's Name - City <br /> Address Business`Phone �^ <br /> Contractor's Name �'P License# �� <br /> �^ Emergency Phone t <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes_ <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN 13RECONDITION 13 _DESTRUCTION❑ G <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT 13 OTHER <br /> ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` lI <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation--,A <br /> OMESTIC/PRIVATE <br /> 13 DRILLED Dia. of Well Casing P <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1"�GRAVEL PACK Depth of Grout Seal <br /> 7❑ IRRIGATION e r4 <br /> 13 CATHODIC PROTECTION ROTARY Type of Grout <br /> I Ptah <br /> ❑ DISPOSAL 11 OTHER Other Information <br /> Surface Seal Installed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H P. <br /> Type of Pump <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> Well Diameter {r <br /> DESTRUCTION OF WELL: �J <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 /> aquin Local Health District. <br /> ordinances, state laws, and rules and regulations of the San Jo �� <br /> i <br /> Home owner or licensed agent's signature certifies the following."I certify that in the performance otthe 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 far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." - <br /> I will call fora Grout I spe.ction prior to grouting and a final inspection. l <br /> I Title: _ r r Date. <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> PHASE k J <br /> Date,Y, / <br /> Application Accepted By <br /> # Additional Comments: _ <br /> Phase III Final Inspection <br /> a 1 out Inspection /"~J F-7— <br /> r �/ Inspection By Date <br /> I Inspection By Date <br /> } Fee Is Due: 13 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> i -'BASE "" —EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS s - <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER - P <br /> Received by Date <br /> Receipt No Permit No: issuance Date Mailed' Delivered <br /> � 1605 E.NAZELTON AVE",P.O.Bolt 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />