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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />` FOR OFFICE USE: APPLICATION <br /> r <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> k <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 /> made in compliance with San Joaquin County Ordinance N,9 and the rules d regulations of the San Joaquin Local Health District. <br /> Exact Site Address A .l� City/Town <br /> Owner's Name �Y`" 1, -r a Phone <br /> Address Xft ,*". r gool end city <br /> Contractor's Name License# Business Phone62. <br /> Contractor's Address Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK CHECK): NEW WELL❑ DEEPEN I RECONDITION❑ DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® <br /> REPLACEMENT❑ <br /> r <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 /> 1 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 10 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _t <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 to <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ® State Work Donee E.� • , . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> 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 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 Ins ed prl r'to g uting and a final inspection. f <br /> Signed ills: U� 't _ Date: <br /> v (Draw Plo Pian on Reverse Side) <br /> f ; FOR DEPARTMENT USE ONLY <br /> PHASE r <br /> Application Accepted.By Date <br /> Additional Comments: <br /> Phase'll Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 3 Ll f <br /> .tom- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE "❑ EACH- ❑ January 1 &Received By January 31 ❑ July &Received By July 31 <br /> _ BILLING .REMITTANCE. $ _ RE <br /> MIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED P <br /> / d� r AMOUNT <br /> FEE cr <br /> LESS 1 Ct�J T <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ,, ii - p <br /> S`t6-3 ;i— <br /> Received by Date Receipt No Permit No. Issu nce ate.. . . Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />