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'Appllcations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r �, <br /> FOR 6,)'FICE 1.19t:' APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> t PUMP&WELL <br /> t <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 /> F made in compliance210 <br /> n)71 Coun Ordinalwe No. ,$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �% "� City/Towni <br /> Owner's Name Phone_ <br /> Address C3' ll City 1 <br /> Contractor's Name License#,L Business,.-}cone <br /> C;Ap <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensa ion Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WEItL A ,AN NMEN�� OTHER ❑ ' PUMP IN.STALLATIOf�i ❑ PII�MP RFEPAIR❑ <br /> REPLACEMENT GLI ��C- ��✓/� � .. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> f Sewage Disposal Field Cesspool/Seepage Pit Other <br /> y Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑INDUSTRIAL "" ❑ CABLE TOOL Dia. of Well Excavation C 1 <br /> t 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 f ro,.. Surface Seal installed By: <br /> t ° <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump '- H.P, j <br /> PUMP REPLACEMENT: u ❑ State Work Done <br /> i PUMP REPAIR: ❑ State Work Done <br /> s DESTRUCTION OF WELL, Well Diameter Approximate Depth <br /> it 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 /> f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> f <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 /> r, permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> x I will call for a Grout I pection prior grouting and a final inspec ' n. ~- ,J <br />` Signed X Title: / Date: <br /> (Draw Plot Plan on4Weverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date yllz jg� <br /> 1 Additional Comments: <br /> Phase 11 Grout Inspection Phaseal Inspection c� <br /> r Inspection By-/,— Date Inspection B Date <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 /> �t BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE $ <br /> REMITTED AMOUNT DUE CHECKED <br /> �} AMOUNT <br /> FEE t i 8.11 '►p <br /> LESS <br /> PRORATION s <br /> PLUS <br /> PENALTY <br /> 44f <br /> I OTHER P <br /> I <br /> ,i <br /> OTHER 1i 1 <br /> .: ! <br /> Received by '- .. Date ir Receipt No- Permit No- Issuan a Dale Mailed Del red <br /> 6 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 I <br />