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- Applications Will Be Processed WhC Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto 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 oaq in LocalHealth District. <br /> Exact Site Address 11� V City/Town <br /> Owner's Name Phone <br /> Address City ' <br /> Contract7Name License#, ls5i 7l ZBusiness Phone <br /> ContractEmergency Phone <br /> I <br /> Is Certificman's Compensation Insur ce on File With SJLHD? Yes �� No ` <br /> TYPE OF WORK (CHECK): NEW WELL C] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTEI-- ; <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines f' Pit Privy_" <br /> Sewage Disposal Field ' 1 Cesspool/Seepage Pit � ,Other �r <br /> Property LineLCZ_t4 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 Cl 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <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. a <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit iv <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> wil caH fora rout In eciion prior is grouting and a final inspe n. J <br /> Signed X Title: Date: � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Dat <br /> Additional Comments: <br /> Phase N Grout Inspection Phase It Final Inspection r� u <br /> Inspection By Date Inspection By Date 7 v <br /> G Fee Is Due ❑ ANNUALLY PER UNIT PER SITE 13 EAGH. ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 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.Baa 2009 STOCKTON,CA 95201 <br />