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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. € <br /> FQR"OrFICE-USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> -- ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) Cj , �C L1s�_�✓77�/ MATkR QUALITY t <br /> Application is hereby made tothe San Joaquin Local Health District ora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit Jo qui County Ordinan�No. f862 and the rules an regulations of the San Jo quin Local Health District. <br /> Exact Site Address i1�- City/Town , <br /> Owner's Name Phone I <br /> Address City <br /> Contractor's Namo (y <br /> m License#01Z�_ 13 siness Phone s •� <br /> Contractor's Address d Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes :X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR4 d r <br /> REPLACEMENT❑ <br /> 1 <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 ❑ 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter ! ApprXimate 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. f <br /> Homeowner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspe n. m <br /> Signed X - -7Q� �{ ;TC__ Title: <br /> (Draw Piot Plan on' everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection @ III F' at n <br /> Inspection By Date Inspection leg <br /> Fee Is Due: ❑ ANNUALLY [I PER UNIT El PER SITE 13 EACH El January 1 &Received By January 31 ,❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` 40 <br /> LESS <br /> PRORATION <br /> PLUS OW <br /> PENALTY f;H11 <br /> OTHER <br /> OTHER 1 <br /> Received by n Date Receipt No. Permit No. 'Issuance Dafe Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />