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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.o'PFiCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable)} <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) � �� WATER QUALITY <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 /> made in compliance wi Sa Joa pin Caunty Ordinanc Not 1862 and the r and regulations of the San Joaquin Local Health District. <br /> Exact Site Address +� ' • City/Town <br /> r <br /> Owner's Name <br /> Address Phone <br /> City , E <br /> Contractor's Name �� License Business Phone <br /> Contractor's Address Emergency Phone -740 X <br /> Is Certificate of WdF•Jcl Compensation Insurance on File With SJLHD? Yes No I <br /> TYPE OF WORK:(CHECK) NEW WELL" DEEPEN ❑ RECONDITION❑ DESTRUCffOIV❑ <br /> WELL CHLORINATION.❑ a4„ WELL ABANDONMENT 0 OTHER ❑` PUMP INSTALLAT,6NI'PUMP REPAIR❑ ��4 <br /> REPLACEMENT, , � <br /> ami ' ' ~k '� �, vs I <br /> DISTANCE TO NEAREST:-, Septic Tank-1 V. �o . - wer-Lines_r.W <br /> -- Pit Privy— V _x <br /> Sewage Disposal'Field CesspoaVS- page Pit. ^ n Other <br /> Property LineA�--Private Domestic Well64! Public Domestic Well <br /> INTENDED USERYPE Ol=WELL`.` <br /> ❑ INDUSTRIAL ` A <br /> if❑ <br /> CABLE TOOL-- _ Dia. of Well Excavation <br /> 'DOMESTIC/PRIVATE DRILLED'" y T�__ <br /> .�-� Diaaof Well Casing R+ <br /> ❑ DOMESTIC/PUBLIC I❑ DRIVEN <br /> Gauge f Casing _ <br /> ❑ IRRIGATION II❑,:GRAVEL PACK Depthof Grout Seal <br /> ❑ CATHODIC PROTECTION VARY Type of Grout ^ <br /> ❑ DISPOSAL 10. OTHER Other Inform'tion= <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor Surface Seal Instal By: <br /> Type of Pump • H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done s { <br /> PUMP REPAIR: 11 State Work Done -" <br /> DESTRUCTION OF WELL- Well Diameter i V <br /> Approximate <br /> Describe Material nd Procedure <br /> I hereby certify that I have prepared this i1oplicationrend that the work will be done in accordande,with San Joaquin County, <br /> ordinances, state laws, and rules and regulativri"s of the San Joaquin Local Health District. <br /> �*, <br /> t, <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."— <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 empfoy,persons subject to workman's compensation laws of California:" <br /> I will C or a Grout Inspection prior to grout' g nd a final inspection. <br /> Signed X Title: _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> *. FOr EPARTMENT USE ONLY <br /> PHASE f <br /> Application Accepted By bat { <br /> Additional Comments: <br /> __Phase 11 Grout Inspection Phase III Final Inspec#ion <br /> Inspection By r Date Inspection By Date <br /> { <br /> Fee Is Due: 11-`-ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ' ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> �y DATE RATE REMITTED AMOUNT DUE CHECKED <br /> FEELESS <br /> t. ✓ <br /> PRORATION jl <br /> PLUS r <br /> PENALTY 40,. <br /> OTHER Ip <br /> OTHER <br /> /7'7 <br /> Received by Date - Receipt No. Permit No. Issuance Date` Mailed <br /> Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 95201 <br />