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ApplicationsWilt Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,'Revocable, Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL i <br /> (COMPLETE IN TRIPLICATE) 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 aplicatioh is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an a rules and regulations of the San Joaquin L cal Health District. <br /> Exact Site Address. City/Town <br /> Owner's Name CJ of YI. U r Phone <br /> Address City <br /> Contractor's Name License# Business Phone { <br /> Contractors Address 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❑ DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ Pf I <br /> REPLACEMENT❑ UMP REPAIR �I <br /> "DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 3 <br /> Property Line Private Domestic Well 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing x <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information oZj <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done 4r GrS q�- <br /> DESTRUCTION OF WELL: Well Diameter pprpximate 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." i <br /> Conirac is hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit issue I shall employ persons subject to wor 's compensation laws of California." <br /> yj <br /> I will 11 for Grout Inspection pr ti d Inal inspection. <br /> Signed X itle: Y Date: CJ <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> F R DEP RTMENT USE ONLY <br /> P SE I <br /> Application Accepted By Date y <br /> Additional Comments: K <br /> a <br /> Phase II Grout Inspection hase III Final Inspecti <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar <br /> y 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE REMIT - <br /> BASE EXPLANATION $ A <br /> _ DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER k <br /> OTHER <br /> Received by ,. Dae Receipt No, " - Permit No. S Issuance ate Mailed Delivered <br /> - - APPLICANT—RETURN"ALL COPIES TO: ENVIRONMENTAL HEALT1 -PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,GA 95201 <br />