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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> lX (For Nan-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 1 <br /> Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconstructand/orinstallthework herein described.This application is <br /> made in compliance with San Joaquin Co 1ty dinance No. 8862 a l the rules and regulations of the San Joa tri District. <br /> Exact Site Address U City/Town e� <br /> Owner's Name J f ` Phone <br /> Address City <br /> -� <br /> Contractor's Name cense# hone � <br /> Contractor's Address Emergency 9��No <br /> 1 <br /> Is Certificate of Workman's'Compe satio Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WE L❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑, -0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2" PUMP REPAIR❑ <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 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13 5DUSTRIAL C1CABLE TOOL Dia. of Well Excavation <br /> 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 Surf a Seal 1pqalled By: ) <br /> � 3 <br /> PUMP INSTALLATION: Contractor , p <br /> Type of Pump '._ H.P.? z <br /> Lam./ <br /> PUMP REPLACEMENT: ElState Work Done 1 <br /> PUMP REPAIR: ❑ State Work Done <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 r <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 /> 1 <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 iss ed, I shall employ rsons subject to workman's compensation laws of California." <br /> I will C r Grout Inspect! 1 to grouting d a final inspection. <br /> Signed X Y itle: Date: i <br /> (Draw Plat Plan on Re rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> — Date <br /> Additional Comments: 1 <br /> Phase II Grout Inspection � hose ill Final Inspection <br /> Inspection By Date Inspection By ¢ % Date –1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> - <br /> AMOUNTt <br /> FEE <br /> LESS YR <br /> [ t <br /> PRORATION <br /> PLUS <br /> PENALTY "1 <br /> OTHER <br /> • f <br /> OTHER <br /> 170�3n } <br /> Received by - Date Receipt No. Permit No. Is uanre Pate Mailed _Delivered J <br /> - APPLICANT--RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 1 <br />