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Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheAppileation. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-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 District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Duncan Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name �I Drillers Drilling Car License# Business Phone <br /> 'T-371' <br /> Emergency Phone <br /> Contractor's Address a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes K No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 1:1 OTHER 11 PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <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 N <br /> -9DOMESTIC/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 7 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 111"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 {rj <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." 3 <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 persons subject to workman's compensation laws of California." 3 <br /> I will call for a Gro t Ins ction prior to grouting and a final inspect. 7U <br /> _,/ <br /> Signed X <br /> r Title: f��'11C1':t Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> � 1{ <br /> PHASE I r ~u, ,' «— ? Date <br /> Application Accepted By- <br /> Additional <br /> ay Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> s Fee IS UUe: ❑ ANNUALLY PER UNIT PER SITE ElEACH ❑ January 1 &Received By January 31 ElJuly i &Receiv REMITBy uly 31 <br /> BILVNG REMITTANCE $ AMOUNT DUE CHECKED <br /> ASE EXPLANATIONS <br /> DATE DATE REMITTED AMOUNT <br /> FEE t^ <br /> LESS .s <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> im a �sr� I� �a <br /> Received by ate Receipt No. Permit No ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />