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e Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOA OFFME USE: APPLICATION <br /> (For Non-Transierahle,'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 akpermit to construct and/or install the work herein described.This application is <br /> made in compllanc `ith.San Joaquin Count Ord_inance No 8 and the. rules and regulations of the SaJoaquin Local Health District. <br /> /�� U' .. Cit <br /> Enact Site Addres �_� City/Town <br /> - <br /> ..R - r 3 .�s.-,. •ra <br /> Owner's Nam ` Phone <br /> Addressr, City r w <br /> r1.. lL. <br /> Contractor's Name _ ` ' ' Li6ense E� % t Business'Phone �— <br /> Contractor's Address merg$ncy Phone <br /> Is Certificate of Workman's Compensation insurance on File With.SJL D? Yes No f ^, <br /> TYPE OF WORK (CHECK):" NEW WELL❑: DEEPEN ❑`"' - RECONDITION❑— r DESTRUCTION V" <br /> WELL CHLORINATION 13 WELL ABANDONMENTi.❑ OTHER E] . PUMP INSTALLATION � PUMP REPAIR❑ <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 TYPE OF WELL <br /> ❑, IN USTRIAL - ❑ CABLE TOOL Dia. of Well Excavation <br /> 13 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 /> ❑ GEOPHYSICAL a Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �_��--' H.P. <br /> PUMP REPLACEMENT: _ - ❑ State Work Done <br /> MP REPAIR: ❑ State Work Done <br /> I PU -_1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 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 for which this <br /> permit is'issued,`i shall employ persons subject to workman's compensation laws of California." <br /> S 1 will for a Grgut spection prior to grouting and a final.inspection. /. <br /> Signed Title: Dately �_/ 2— 1 w <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase If Grout Inspection + Phas I al Inspection r k i <br /> Inspection By Date — Inspection By Date <br /> 44. <br /> Fee Is Due: ❑-ANNUALLY ' '- ❑ PER UNIT' ❑ PER SITE ❑ EACH - ` ❑ January 1 &Received By Janua ❑ July 1 &Received By July 31 <br /> BILLING .r } REMITTANCE $ REMIT <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE t <br /> r <br /> PRORATION <br /> PLUS, <br /> PENALTY <br /> OTHER <br /> OTHER . <br />. Received by Date- Receipt No. P rmit No. Issu nce Wle Mailed Delivered - <br /> I, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />