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m Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE; APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 4� <br /> ENVIRONMENTAL .HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ..-. S <br /> 11 <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 ano thp, rules and egulations of the San JoaquinLocal Health District. <br /> Exact Site'Address �a< City/Town e J <br /> S <br /> i <br /> Owner's Name' - -' Phone <br /> Address ^ a City <br /> Contractor's Name GAP License# .,�Business Phone 5 { <br /> fCry / Emergency Phone 4 <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No _ _ y i <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <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 /> EI-6 MESTIC/PRIVATE ❑ DRILLED ilia. of Well Casing <br /> ❑ bOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL: Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor~ <br /> Type of Pump [ '-- H.P. <br /> PUMP REPLACEMENT: S-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 /> Home owner or Iicensed 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 /> r <br /> I I call f r a Grout Ins ecdon prior to grouting and a final inspection. <br /> r <br /> Sign _ Title: Date: •� <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date �� 6 <br /> Application Accepted By <br /> Additional Comments: <br /> ' Phase Ii Grout Inspection Ph' II 'nal Inspection <br /> Date Inspection fay <br /> Date <br /> „ Inspection By „ ._ _ y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 4 &Received By July 31 <br /> REMIT <br /> 1, BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ;I LESS - x - <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER a <br /> �h OTHER ' <br /> Received by Date Receipt NO.' Permit No. Issuance Date Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2609 STOCKTON,CA 95291 <br />