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F <br /> Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ---- I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ( { <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> € made in compliance with San JoaqWip Count Ordi ante No. 1862 and the rules and regulations of the San Joaqu_i_n/Lgcal Health District. <br /> Exact Site Address City/Town <br /> L, Phone <br /> Owner's Name <br /> Address V'C- City <br /> ' Contractor's Name a« License# 1�– 77 XV Business Phone !` <br /> I Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fil h ? Yes.__..__._ c No <br /> F TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION E] , <br /> j WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> k Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE 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 ,;„ Surface Seal Install y: <br /> 1 PUMP INSTALLATION: Contractor <br /> I <br /> s Type of Pump H,P. <br /> PUMP REPLACEMENT: �❑ State Work Done <br /> PUMP ROPMR: State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' Describe Material an`d 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 /> Home owner 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 persons subject to workman's compensation laws of California." <br /> i <br /> I i call for a Grou spectio i r o r ulin nd final inspection. <br /> Signed X r itle: [ <br /> Date: .. <br /> {Draw'Plot anon Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER�UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> t. <br /> REMIT <br /> BASE 1EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> { <br /> I) DATE DATE REMITTED AMOUNT <br /> FEE S i F 5 t4S <br /> LESS f <br /> PRORATIONPLUS <br /> J <br /> PENALTY <br /> OTHER } <br /> i <br /> OTHER f <br /> s a,53� <br /> Received by Date ' Receipt No, Permit NoIssuan DTteJ iled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: *�ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZE TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />