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Applications Will 8e Processed When Submitted Properly Completea. lie sure iosign 1nersppncanvn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non=Transferable, Revocable, Suspendable) <br /> PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I 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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 3�3 41F City/Towne <br /> 'Owner's Name Phone <br /> Address City <br /> Contractor's Name License#� {_ Business Phone ���� f <br /> Contractor's Address ��.0 i 1fl _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �- No <br /> TYPE OF WORK (CHECK}: NEW WE hL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 Leine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑�-,,�INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> brDUMESTIC/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 /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Aa_ 1-Qr1H.P. <br /> PUMP REPLACEMENT: <br /> 13 state Work Done <br /> PUMP REPAIR: j❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 Gies 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 /> I 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 /> will I r a Grout In pectian prior to grouting and a final inspection. <br /> 0Title: Date: <br /> Signe <br /> I` (Draw Plot Plan on Reverse Side) <br /> G JI <br /> p FOR DEPARTMENT USE ONLY - <br /> I PHASEI <br /> Application Accepted By Date Z Q <br /> I Additional Comments: <br /> r Phase 11 Grout Inspection Ill Final pection <br /> Inspection By -Il . Date Inspection ,. ��ate <br /> n s-tea <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> tBILLING REMITTANCE $ REMIT <br /> EXPLANATION AMOUNT DUE CHECKED <br /> BASE " <br /> DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE .. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> l[r OTHER <br /> - � 0 <br /> ! va car_ 's [3 <br /> Received by pate �N Receipi No, r i Is uance bate .Mailed Deli ed <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />