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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 /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,I�1r BS WATER QUALITY D 2- <br /> Application <br /> Application is hereby made totheSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S n Jo quin C unty Or ce No. 1 and the ules an r gul io�Ly'���o�f�h�� oaquin Lo I Heal h District. <br /> Exact Site Address 'C:nyfTown �C�Si/a n/ <br /> Owner's NamePhone <br /> Address9. City <br /> Contractor's Name 0c, (cense 4, Business Phone <br /> Contractor's Address' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Ud <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> 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/S9epage Pit �-- Other <br /> Property Linei/_ Private Domestic Well `S Public Domestic Well <br /> INTENDED USE TYPE OF WELL U <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t/ } <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION J<GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION IlkROTARY Type of Grout AE�FN <br /> ❑ DISPOSAL ❑ OTHER Other Information �^ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Ae r <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 <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 far which this <br /> permit is issued, I shall employ persons smbject to workman's compensation laws of California." <br /> I will for a Gro nsp n p r grouting and a final inspection. f <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reversei e) <br /> FO DEPART ENT USE ONLY <br /> PHASE <br /> b <br /> Application Accepted By Date <br /> Additional Comments: <br /> /hhfGrout Inspection q r� P se III Final Inspection <br /> y 11 <br /> Inspection Date `2��D Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 659 [ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />