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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si n The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin ounty�Qrdinance No. 1882 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name <br /> I Address - Phone <br /> n � <br /> Contractor's Name City I <br /> License# �/_ Business Phone <br /> Contractor's Address Emergency Phone +( <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �< — No <br /> TYPE OF WORK (CHECK): NEW WELL❑ -m <br /> DEEPEN ❑" RECONDITION IJ pESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION PUMP REPAIR W <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 f <br /> INTENDED USE i TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing s F <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> C1 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 <br /> PUMP REPLACEMENT: I El State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter 1 <br /> } Approximate Depth <br /> It Describe Material and Procedure l <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. a <br /> Home owner 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 manger 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's connpensation laws of California."" + <br /> I will call r a Grout I spectiprior to groulittgyand a final inspection. �- <br /> Signed X <br /> Title: - <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE ; ? x <br /> Application Accepted By <br /> € k <br /> Additional Comments: Date <br /> .,.� _ , <br /> Phase II Grout Inspection T - 0;W1 <br /> inal InspectionInspection By Date.. Inspection By! Date <br /> 1 q '.� . . L. <br /> Fee IS Due; ❑ ANNUALLY �0 PEA-UNIT—[3-PER'S1T-E S - } <br /> - +• ❑,EACHs—i ?"[E�`January 1&Received By January 31' � uly? &Received By July 31 <br /> BASE - EXPLANATION BILLING REMITTANCE ti�+ $ REMIT - <br /> DATE AMOUNT DUE „CHECKED <br /> DATE —REMITTED-- <br /> ._,_- AMOUNT <br /> FEEqs <br /> �y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' r <br /> OTHER <br /> Receivetl by Date <br /> Receipt No, 4 Permit No. _ . Issua ce❑ate Mailed Oelrvered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />