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Applications Will Be Processed When Submitted Properly Completed. Be Sure o gn a pp <br /> FOR OFFICE USE: APPLICATION <br /> � (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ' t - <br />` -Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew <br /> ork.hereindescribed.Thisapplicationis <br /> ce.No.1862 and the rules and regulations of the San Joaquin rocal� Health District. <br /> made in compliance with San Joaquin County`Ordinan <br /> Exact Site Address City/Town <br /> Phone <br /> Owner's Name .� <br /> Address - City <br /> S ' Business Phone" / Y "r?G ? � <br /> Contractor's Name .�� D License f# ' <br /> Contractor's Address <br /> .�+ - Emergency Phone - c <br /> Is Certificate of Workman's Compensation insurance on File Wi SJLHD? Yes NO <br /> _ � <br /> TYPE OF WORK (CHECK): NEW WELL❑ .DEEPEN El RECONDITION. DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR <br /> p- REPLACEMENT❑ - _ - - - <br /> DISTANCE TO NEAREST: Septic Tank Sewer tines Pit Privy <br /> Sewage Disposal Field .LGesspool/Seepage Pit Other <br /> Property Line Private Domestic.We Public Domestic Well <br /> INTENDED USE TYPE OF WELL �.. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well"Excavation <br /> 4 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL c. Surface Seal Installed By: <br /> PUMP INSTALLATION: + Contractor "'" 3 <br /> Alp <br /> Type of Pump H.P- <br /> ❑ State Work Done _ I } <br /> PUMP REPLACEMENT: <br /> State Work Done � c <br /> t PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL. Well Diameter '. <br /> Describe Materia! and Procedure <br /> 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 /> Home owner or licensed agent's signature certifies the following'."I certify that in the performance of the work for which this permi"t <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 r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Cajfornia." r <br /> 1 wild callfora Gro t"I -p'-e on or to g.o Ing an a final inspection. i <br /> Tltlei Af �.. _ Date: <br /> Signed _ , <br /> r (Draw Plo Ian on Reverse Side) <br /> k! <br /> FOR DEPARTMENT USE ONLYTk;� <br /> I <br /> PHASE 4 ... ti.w rnj Date - <br /> Application Accepted By ` k <br /> Additional Comments: <br /> Phase II Grout Inspection _ Phase III Final Inspection F <br /> �l1 1n I Date r Inspection By `-'1'�• -- Date <br /> Inspection By .��rpm <br /> Fee IS Due. C1 ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 E] July 1 &Receiven-d B�yl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> s v <br /> FIFE <br /> � <br /> LESS - <br /> PRORATION - - - <br /> l. PLUS F <br /> PENALTY <br /> OTHER •..;•_ <br /> OTHER - <br /> - Received-by - <br /> Date Receipt No. Permit No. Issua ce Date. -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />