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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> 4QR OFFICE USE: APPLICATION <br /> =� (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY .. <br /> Application is hereby made to the San Joaquin Local Health D <br /> istrictfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County OrdinanceNv.1862 and the rules and regulations of the San Joaquin,Local Health District" <br /> Exact Site Address 1 l <br /> j City/Town <br /> Owner's Name r Phone 3 <br /> Address le 1 <br /> City <br /> Contractor's Name T License#&.� 11 41 Business Phone r <br /> Contractor's Address 'J 'Emergency Phone <br /> - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes._ _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 4 RECONDITION❑ DESTRUCTION❑ <br /> WELL' CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -� <br /> Sewage Disposal Field ,SCS —Il Cesspool/Seepage Pit - Other <br /> Property Line- + Private Domestic Well� Public Domestic Well <br /> INTENDED USE r,t TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOO_ L Dia. of Well Excavation I EK1SZ1 Vq LA)Z <br /> 04 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' c S <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing A LL)r r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout -� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done W <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <br /> 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 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 \ ' <br /> permit is issued, I shall employ pZ <br /> ons subject to workman's compensation laws of California." r <br /> I will II for a G ut I ec r to grouting and a final inspection. <br /> Signed X Title: Date: <br /> /.;7_ Q12,� . kZ <br /> (Draw Plot Plan on Rev a Side) <br /> i <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date �-/ <br /> Additional Comments: <br /> Phase li Grout Inspection hase III Final Inspection k <br /> Inspection By Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE( REMITTED } AMOUNT P <br /> FEE ,. S4Ee fir'% Ef p3 !:,7f i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER f - <br /> ct <br /> Rec ived by - Dalle <br /> Receipt No Permit No, - Issuance Date - Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE„P.O.Box 2009- STOCKTON,CA 95201 <br /> ti ' <br />