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Applications Will Be Processed When Submitted Pr:? '1,_ .. <br /> I Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> + (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San oaquw Local Health Di trictfora rmit to construct and/or install the work herein described.This application is <br /> made in compliance with S rr I L n �e and regulations of the San Joa Loca) alth,District. <br /> Exact Site Address r r City/Town <br /> Owner's Name L. <br /> _ Phone <br /> Address [j J City r <br /> Contractor's Name License# CST%�l Business Phone <br /> Contractor's Address 'Jr Emergency Phone <br /> t is Certificate of Workman's Compensation Insurance on Ile With SJLHD? Yes -- No <br /> r <br /> TYPE OF WORK (CHECK): NEW WELLA 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 Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL ❑ <br /> CABLE TOOL Dia. of Well Excavation � r,•�,tJ�uGrr✓�� <br /> f ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing l _ <br /> A DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I ❑ IRRIGATION EK GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 61g, <br /> r ❑ DISPOSAL ❑ OTHER Other Information dpr, <br /> ❑ GEOPHYSICAL Surf a Seal Installed By: <br /> PUMP INSTALLATION: i Contractor ,4 „=N <br /> Type of Pump H,P. i <br /> PUMP REPLACEMENT: 1.0 State Work Done <br /> PUMP REPAIR: El State Work Done <br /> DESTRUCTION OF WELL: -r*iNell Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certif .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 /> Home owner or li nsed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit <br /> r is issued, 1 sh not mploy any person in such manner as to become subject to workman's compensation laws of California." i. <br /> Contractor's firing gsub contracting signature certifies the following:"I certify that in the performance of the work for which this + <br /> permit is iss ed, I all m loy p�r ons su ct to workman's camp sation laws of California." <br /> I will call rou i s ctio i t grouting and a final inspecii _4 <br /> Signed X Title: 'r Dale: 1 ` <br /> (Draw Plot Plan on R verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> Application Accepted By Date �' ''�Sa <br /> f Additional Comments: - b� <br /> hase li Grout Inspection a III F• at Inspection <br /> Inspection By Date�Z" —$0 Inspection By Date "l / <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE -❑ EAGH ❑ January 1 &Wcelved By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date f Receipt No. - ermit No. (Is ante I to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE.,-P.O.Box 2009 STOCKTON,CA 9 <br /> 1 I <br />