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Applications Will Se Processed When Submitted tteedProf <br /> FOR OFFICE.USE: y <br /> c (Far Non-Transferabl vocable, Suspendable) <br /> c� PUMP&WELL <br /> ENVIRONMENT EAPfIIaPl1�PF'a <br /> WATER QUALITY py /pSN <br /> (COMPLETE IN TRIPLICATE) �rta{work herein described.This application is t <br /> Application is hereby madetothe San Joaquin Local Health Districtfora ermi ,��T <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rule t As of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name <br /> 4 License# cty��° <br /> Address �. �� <br /> Contractor's Name <br /> �_— ' �-b�/�� Business Phone <br /> Contractor's Address ��/f , —� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance an File With SJLHQ? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRt� <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 <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL .. -. , <br /> ❑ CABLE.TOOL .. -Dia. of Well-Excavation• - - <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE I <br /> I ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC <br /> C1 GRAVEL PACK,- Depth of Grout Seal <br /> El IRRIGATION .. n <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: 11 tate Work Done , <br /> PUMP REPAIR: state Work Done Ae <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> k 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 fallowing:"I certify that in the performance of the work for which this permit <br /> t 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 I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: -ED <br /> Signed X <br /> (Draw Plot Plan on Reverse Ide) <br /> `°_FO DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: +` <br /> Phase ll Grout Inspection Phase III Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT 'PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED~ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE � t� <br /> X� <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> s <br /> OTHER <br /> 'OTHER <br /> IDate INo. <br /> Permit Na. Issuance Date Mailed Delivered <br /> - Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON-AVE.,P.O.Sox 2009 STOCKTON, Y— <br />