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Applications Will Be Processed When Submitted Properly Completes. se sure 1osign 1rteAppuca <br /> FOR OFFICE USE: APPLICATION <br /> (For Nor]-Transferable, Revocable,Suspendable) <br /> ',Z � � PUMP&WELL � <br /> Zl ENVIRONMENTAL HEALTH PERMIT �- <br /> (COMPLETE IN TRIPLICATE) �F T� WATfR QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with3ag,J quip Ca11n.tY_O rdilancjNo. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address !l�yf Ez�1QTT �" City/Town AR�o <br /> Owner's Name Phone <br /> Address � +� tileTr' City <br /> Contractor's Name License#337aff ZBusiness Phone <br /> Contractor's Address Emergency Phone 7 <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 ❑ PUMP REPAIR 11 <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line§ 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 /> �,C <br /> �I INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> +r <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing - <br /> I DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �Q <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout — <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor VI <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: I] State.Work_Done <br /> PUMP REPAIR: ❑ 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 Go11 for a Grout Inspects or grousing and a final inspection. <br /> Signed X _ Title: date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD EN ARTMUSE ONLY- <br /> Application <br />= PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pha II Grout Inspection Ph a Final I ection <br /> Inspection By Da �' 7 _ Inspection By to 3-3� <br /> Fee Is Due: ❑ ANNUALLY © PERUNIT ER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br />