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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. , <br /> FO OFFICM USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin C unty Oy4ance No. 1862.and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Tow, <br /> Owner's Name -1. Phone <br /> Address ' City <br /> Contractor's Name C6` License#, ad•(a Business Phone 3�- <br /> Contractor's Address cC1Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes i(✓ No <br /> TYPE OF WORK (CHECK): NEW WELL ❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑,- PUMP REPAIRS' 4 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lin_a 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 /> ❑ GEOPHYSICALy w _ Srface Seal Installed By: <br /> PUMP INSTALLATION: Contractor S( A� -t <br /> Type of Pump <br /> PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: State Work Done y <br /> DESTRUCTION OF WELL: Well Diameter T Approximate Depth I <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 /> 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 toe following:"I certify that in the performance of the work forwhich this <br /> q permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II for Gr t spection prior to grouting and a final inspect- y <br /> Signed X + �y""� Title: —� �s - Date. �yAk <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 1 ) <br /> PHASE I l �'2..CL. � Date <br /> Application Accepted By-; <br /> Additional Comments: <br /> Ph a II Grout Inspection P se fl final Inspection <br /> Inspection By Date 1 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January`-! &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE. REMITTED AMOUNT <br /> e <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> Received by, Date Receipt No. - - Permit No. Issuance Date Mailed - Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2009 STOCKTON,CA 95201 ' <br /> ' I <br />