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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFE E USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 Joa in Cqpnty Ordinance No. 1862 and the rules and regulations of the Sanli=nLocal Health District. <br /> Exact Site Address °f 7 City/Town <br /> Owner's Name Phone ' ; <br /> Address City <br /> Contractor's Name License 37_3 Business Phone <br /> Contractor's Address Emergency Phone 'Pe`6 r4?fu <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes &�,_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E!r 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-weal=Excavates <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> o-DOMESTIC/PUBL[C _ _ _- __ —O DRIVEN__ _. GaugeotCasing-`-.._ <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL urface Seal Installed By: <br /> PUMP INSTALLATION:: contractor <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: tate 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 1 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:"1 certify that in the performance of the work forwhich this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> w" all t a Grout ection prior to grouting and a final inspection. <br /> Signed X Title: !i tf Date: —' ^ <br /> (Draw Plot ,Ian ort Revers— _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> App enation-Accepted_By_ _ _` r Date'. <br /> Additional Comments: <br /> Phase II Grout inspection Pha of Final Inspection <br /> Inspection By Date Inspection B Dare <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑EACH ❑ January 1 8 Received By January 51 ❑ Jult7&Received By July 37 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION 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 N& IsIsuance a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 9S201 <br />