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apPltionsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO FFIC USE: APPLICATION <br /> 4A (For Non-Transferable, Revocable, Suspends <br /> ENVIRONMENTAL ,� EI PUMP&WALL <br /> i- <br /> (COMPLETE IN TRIPLICATE)�3� F�.6a}c�/ [��� <br /> Application is herebymadetotheSanJoaquinLocalHeafthDistrict ittoconstructrinstafltheworkherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 <br /> he r n�{r4gu ions of the San Joaquin Exact Site Addres 7J`'• ,>! �� 'S- quip Local Health District. <br /> CLv(T�Lvn <br /> Owner's Name ���� V , <br /> Address a <br /> Contractor's Name City <br /> ' Licens <br /> Contractor's Ade ] '_ Business Phone. <br /> dress <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> _— OtherPro erty.Line Private Domestic <br /> Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL El CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia, of Well Casing <br /> ❑ :OMESTIC/PUBLIC ❑ DRIVEN <br /> j [ IRRIGATION Gauge of Casing <br /> ❑ CATHODIC PROTECTION 11 GRAVEL PACK Depth of Grout Seal <br /> ROTARY❑ <br /> DISPOSAL Type of Grout <br /> ❑❑ � <br />` GEOPHYSICAL OTHER Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> E <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P.tate Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Describe Material and Procedure Approximate Depth <br /> s <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 inspection. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse-Side <br /> PHASEI FOR DEPARTMENT USE ONLY x <br /> Application Accepted By <br /> Additional Comments: Date ` y <br /> Phase II Grout Inspection c <br /> Inspection fayPhase III Final Inspection <br /> Date Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑..PER SITE <br /> ❑ EACH ❑ January 7 &Received By January 31 - ❑ July i &Received By July 31 <br /> - BASE EXPLANATION BELLING REMI <br /> CE g REMIT <br /> DATE REMITTED AMOUNT DUE CHECKED v <br /> FEE �j AMOUNT { <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> ,OTHER <br /> Receivedby Date Receipt No <br /> Permit No. Iss ante ate Mailed <br /> A APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - Oefivered <br /> 1601 E.HAZELTON AVE.',P.O.Box 2Do9. STOCKTON-CA osDm <br />