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A PP plications Will Be Processed When Submitted Properly CompletedBe Sure To Sig The PP. n Application. <br /> FUfi OFFICE USE: APPLICATION <br /> roh b/0 (For Non-Transferable, Revocable, Suspendable) <br /> r PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (C <br /> t OMPLETE IN TRIPLICATE) WATER QUALITY ' <br /> j Application is hereby made to the San Joaquin Local Health District for a permit to constru'ctand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �E. City/Town <br /> Owner's Named S Phone <br /> f Address �C,ity <br /> Contractor's Nam License# Business Phone C <br /> Contractor's Address .A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WithJ ; <br /> LHD? Yes— No <br /> k TYPE OF WORK (CHECK): NEW WELL 13 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 <br /> ❑ INDUSTRIAL ❑ <br /> I CABLE TOOL Dia. of Well Excavation <br /> 09 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 /> ❑ • <br /> GEOPHYSICAL <br /> F Surface Seal Installed By: V� <br /> PUMP INSTALLATION: Contractor_ 7­2!u <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . L State Work Done a Q <br /> PUMP REPAIF14 ❑ State Work Done 1A <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Sf <br /> I <br /> h 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 /> -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 shah employ persons subject to workman's compensation laws of California." <br /> f I will gall for a Grout Inspection pr to ro ng nd a tin I inspecti <br /> Signed X Date' <br /> (Draw Plot P o ,Reverse Side) <br /> OR DEPARTME T USE ONLY <br /> PHASE I <br /> Application Accepted By Date - <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection l <br /> Inspection By Date J <br /> Inspection By. - Da 6 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- .I i-PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received 13 31 <br /> BILLING REMITTANCE $ RE I <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE <br /> ' LESS <br /> i PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> Received by Date Receipt No, Permit No. Issuanceat[� a Wiled. <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> la ' <br />