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z Applications Will Be Processed When Submitted Properly Completed. 13esure ioWyn InenN1„�a,..,• <br /> FOR OFFICE r."SE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or inance No.1862 and the rules and regulations of the San Jaquin ocal Health District. <br /> I j�u� City/Town <br /> E Exact Site Address �f - JM-- L- <br /> PhoneT <br /> Owner's Name <br /> f City <br /> Address <br /> Contractor's Name <br /> 2 License#�— Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> F TYPE OF WORK (CHECK): NEW WELL) DEEPEN ❑ RECONDITION[) DEST ATCION ❑❑ PUMP REPAiR❑ <br /> TION <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALL ,. <br /> REPLACEMENT❑ / I <br /> DISTANCE TO NEAREST: Septic Tank /nn Sever Lines __� Pit Privy Other _ <br /> Sewage Disposal Fi7ld Cesspool/Seepage Pit -�- - <br /> Property Line_-�Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> �. <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> t <br /> ❑ IRRIGATION 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 /> KID. <br /> Type of Pump <br /> r PUMP REPLACEMENT: ❑ State Work Done <br /> Mt PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> 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 /> permit is issued, I shall employ pe ons subject to workman's compensation laws of California." <br /> F <br /> I wil all for a G out pec k nor to grouting and a final inspection. > <br /> Signed X <br /> Title: - � Date: <br /> i l (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: -i <br /> ( P P se I l final Inspection <br /> ut Inspection I <br /> Inspection B <br /> Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PE SITE ❑ EACH ❑ January 1 &Re ived By January 31 ElJuty 1 &ReceivedByJuly 31 <br /> N MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION ) .. <br /> PLUS f1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A.I Receipt No. Permit No. - Is uance ate Mailed Delivered <br /> Received by Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2{109 STOCKTON;GA 95201 <br />