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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \ <br /> FOR OFFICE USE: APPLICATION <br /> Ca'I.,e A044 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> T ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This applicati©n is <br /> made in compliance with S n Joaquin C�o/4nty Ordtinan a No. 1862 and Pp rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address lIN1D k� t*�4+'?* N ME + W City/Town <br /> Owner's Name �" r 1'h Phone ---. <br /> Address :rZ�OC3 / .S bhp CityQ-�..�-- c'1 <br /> Contractor's Names License# lf39YS` Business Phone__ Z ?C► � <br /> Contractor's Address Oa Emergency Phone — – <br /> Is Certificate of Workman's Compensation Insuranceon ile With SJLHD? Yes— __ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRAI <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 <br /> ❑ DOMESTIC/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 Sea Installed By: <br /> PUMP INSTALLATION: Contractor_ J <br /> Type of Pump -7-,k ✓ b H.P. <br /> PUMP REPLACEMENT: ❑ State 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 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 persons subject to workman's compensation laws of California." <br /> III call for a Grout Ins ctio pri outing and a final inspection. t <br /> Signed Title: T?e --r Date: <br /> 1 <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE a o Date <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phase II Grout Inspection P III on g <br /> Inspection By ___` Date Inspection B <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ClJ nualy-1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> – REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ 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 No. lissuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />