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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFF-ICE @SE: i; APPLICATION <br /> µ w F l (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) !! WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq in unty f" inaapce No i3&2 and the rules and regulations of the San Joaquin Local Health District. <br /> l Exact Site Address City/TownSA <br /> Owner's Name i i1y Phone <br /> Address City r� d <br /> Contractor's ame License#� Bus*iness Phone <br /> Contractor's Address ^ Emergency Phone r <br /> Is Certificate of Workman's Compensatioh insurance on File With SJLHD? YesNo d <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONO DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C1OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI <br /> REPLACEMENT❑ y <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 STYPE OF WELL <br /> ❑ INDUSTRIAL I! ❑ CABLE TOOL Dia. of Wel! Excavation <br /> DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> I DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 13 OTHER Other Information <br /> 11 GEOPHYSICAL Surface Sea! Installed By: t n <br /> M a <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ ,V State Work Done <br /> PUMP REPAIR: ❑ State Work Done # , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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, 1 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 /> F I will call for a Grout Inspection prior to grouting and a final inspect. <br /> Signed )C f oTitle: Date: <br /> u (Draw Plot Plan on We/verse Side) <br /> I - <br /> FORD PARTMENT USE ONLY <br /> PHASE I (� <br /> Application Accepted By, Date <br /> Additional Comments: <br /> jtPha a 111 Final pection <br /> Phase 11 Grout Inspection <br /> Inspection By Date Inspection By to �/Z� Yd <br /> r <br /> Fee IS Due: ❑ ANNUALLY,: ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Ii - REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEF <br /> LESS a <br /> PRORATION . <br /> PLUS <br /> PENALTY i <br /> OTHER �I <br /> t lh <br /> OTHER II <br /> - Received by Date Receipt No, ZPm, o. tl ?u <br /> nc Date Mailed DBlivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />