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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sig heApplication.- <br /> cE USE- <br /> APPLICATION <br /> (For Non-Translerable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -- a0 (24 <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 /> c made in compliance with San Joa uin County 0 inancpl, 1gg2 and the rules and regulations of the San JoaqqU Local Hea istrict. <br /> Exact Site Address <br /> ` City/Towne <br /> Owner's Name <br /> Address <br /> City /L <br /> Contractor's Nam ` License#t. <br /> / , Business Phone r Q <br /> Contractor's Addressx, I�� c�'r� d �� 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLH1 �r' Yu*S <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ No <br /> DESTRUCTION❑ ,Ql�( <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REP <br /> REPLACEMENTAIR© <br /> ! ❑ <br /> DISTANCE TO NEAREST: Septic Tank ,�� f <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Domestic Well Public Domestic Well <br /> INTENDED USE E OF WELL <br /> ❑ <br /> INDUSTRIA CABLE TOOL r� <br /> ❑ Dia. of Well Excavation y <br /> r ►DOMESTIC/PRIVA%TE ❑ DRILLED `,Dia. of Well Casing <br /> OMESTIC/PUBLIC^ ❑ DRIVENGr. <br /> auge of Casing <br /> IRRIGATION ❑ GRAVEL PACK 'Depth of Grout Seal r �uE <br /> ❑ CATHODIC PROTECTION ROTARY .1� i <br /> El DISPOSAL � OT1`lype of Grout <br /> ❑ HER <br /> Other Information <br /> ❑ GEOPHYSICAL w; Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump <br /> PUMP REPLACEMENT.; ❑ State Work Done -� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: # <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> N <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaqI.uin. <br /> 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 thispermit <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 forwhich this 1 <br /> permit is issued, I s employ perso subject to workman's compensation laws of California." <br /> I will call for a Gro Inspe n pri grouting and a final inspection. f <br /> Signed X C Title: _. <br /> Date: y <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTM NT USE ONLY - <br /> PHASEI <br /> Application Accepted By s.� Q <br /> Date U <br /> Additional Comments: � <br /> Ph li rout Inspection Plea e`III Final nspection <br /> Inspection By Date l! � Inspection Bypp, <br /> . Date� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 33 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE AMOUNT DUE CHECKED <br /> DATE REMITTED <br /> Ty� <br /> FEE AMOUNT <br /> d � ' <br /> LESS <br /> PRORATION 5 <br /> PLUS <br /> PENALTY- <br /> - <br /> OTHER <br /> OTHER <br /> Received by - Date ,. -Receipt No. - -Permit No Issuance'Date— Mailed Delivered <br /> APPLICANT AETURN,EIIL COPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> "`° 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />