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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. —� <br /> I FOR OFFICE USE: APPLICATION r <br /> - 4 "" (For Non-Transferable, Revocable, Suspendable) i=. - s• <br /> -� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1 <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 with San Joaquin C nty.Ordinance No. 1862;and the rules and regulations of the Sa Joa uin Luca! Health District. <br /> Exact Site Address ., �e+rfrn � <br /> ' <br /> Owner's Name Phone 7 � <br /> Address - City <br /> Contractor's Name License# 0290?/3 Business Phone <br /> Contractor's Address Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? YesNo 5'« <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank —_7Q !2)"It, <br /> Lines Pit Privy <br /> Sewage Disposal Field``eld `�L� Cesspool/Seepage Pit Other <br /> lF� <br /> Property Lined Private Domestic Well &0 J4 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation. <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ��C!)ILaO�, <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal '.5—e) f _ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ��� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: El State Work Done <br /> 'I <br /> PUMP REPAIR: O.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 /> ' 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 employ persons subject to workman's compensation laws of California." ? <br /> I <br /> I will call for a Grout Inspection prior to grouting and a final inspection. p <br /> Signed X Title: Date: � Ol <br /> (Drai Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By '� Date U ! <br /> Additional Comments: <br /> Phase II Grout Inspe h se III Final Inspection <br /> Inspection By �'j�Q„ g� Z Inspection B o Date V= <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> zl <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �' <br />