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- Applications Will Be Processed When Stitrmitted Properly Completed. Be Sure To Sign The Application. <br /> •01R OFFICE USE: APPLICATION <br /> =' (For Non-Transie'rable,'Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT L 'p <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY !'o'`Y{ ~_� <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein�desdribed.'T_his application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address 'City/Town ,F <br /> Owner's Name tt 's s' Y'CT'E + , ..- .r, �t,-„t Phone <br /> Address cr r >, g .n.io,z v a n City <br /> Contractor's Name ".License#L <br /> _1!�* <br /> Business Phon <br /> Contractor's Address `e9,r j <br /> Emergency Phone!: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): 'NEW WELL'❑ '”"DEEPEN-[]' - RECONDITION❑ ptSTRUCTIO,.�N,,© �� w <br /> WELL CHLORINATION El WELL ABANDONMENT.0- OTHER E] PUMP INSTALLATION IL__ PUMP REPAIR❑ �r <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 <br /> INTENDED USE TYPE OF WELL - J <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC " ; ❑TDRIVEN Gauge of Casing <br /> ❑ IRRIGATION _ �. .___❑ GRAVEL PACK ` Depth-of-Grout Seal- <br /> 0 CATHODIC PROTECTION 0 ROTARY -Type of Grout <br /> ❑ DISPOSAL' ❑ OTHER Other Information <br /> ❑.GEOP.HYSICAL w r Surface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump . - H.P: <br /> PUMP REPLACEMENT: ❑ State Work Don;? <br /> PUMP REPAIR: ❑ 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 rules and regulations of the San Joaquin Local Health District. <br /> t 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 anyperson insuch 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`workrilan's compensation laws of California." ? <br /> }.I will ealljorp Grout Inspe tion prior to grouting and a final Inspection. <br /> Signed X - Title: Date: -� — <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha III' final Inspeclio-w/ <br /> Inspection By _ _' Date Inspection By Date $ r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACHY ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> s BILLING. REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> ' AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> -OTHER <br /> OTHER <br /> Received by Date_ .-. :Receipt No - , Permit No.— , Issuance Dat Mailed Delivered -, <br /> APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />