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Applications Will Be Processed When Submitted Properly'Completed. Be Sure To Sign The Application. f <br /> Foto OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 application is <br /> made in compliance witk�S— ! <br /> an Joaquin County Ordinance No. 1862 an th rules and regulations of the Sa oaquin Local Health District. ' <br /> Exact Site Address 0 �. �i �Z�L� City/Town t rvc lC 7--t— <br /> Owner's <br /> --Owner's Name 0 ' Phone <br /> Address City <br /> Contractor's Name o of a License# Business Phone <br /> Contractor's 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 ABANDONMENTOTHER ❑ 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 R� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 f <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, Q <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter Approximate epth f/'^ &W',h <br /> i � <br /> Describe at eri and Procedure a .ts r/ow." <br /> I hereby certify that I have prep e'd this application and that the work will be done in accordance wmtK San Joaquin County 1', <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 r <br /> permit is iss d, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca r ri ri r to grouting and a final i 'on. <br /> Signed X 4 Title: :-t Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT SE ONLY <br /> PHASE <br /> Application Accepted By ��" f Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase II Final Inspection <br /> Inspection By Date Inspection By Date <br /> f,,r - St <br /> Fee IS Due: El ANNUALLY El PER UNIT _ CJ PER SITE ❑ EACH ❑ ,7anuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT � <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION ECKED <br /> DATE DATE REMITTED AMOUNT DUE AMOUNT <br /> i <br /> FEE L. <br /> LESS <br /> PRORATION, <br /> PLUSl l s <br /> PENALTY __ll <br /> OTHER <br /> r <br /> OTHER Y <br /> Received by Date Receipt No. Permil rVo- Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />