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r ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 1� r�,-N 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 County Ordinance No. 1862 an the rules and regulations of the San Joaquin Local Health DistriPtp <br /> t Exact Site Address r City/Town <br /> Owner's Name Phone <br /> Address <br /> City N j <br /> Contractor's Name License#Z]Zz Zb Business Phone�, <br /> Contractor's Address Emergency Phone 5 :Z zz—"7'-- 1 0 C1 I �} <br /> Is Certificate of Workman's Compensation Insurance on File Wi h SJLHD? Yes K_ No n <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIQ* <br /> WELL CHLORINATION ❑ WELL ABANDONMENT^ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El A <br /> REPLACEMENT❑ Q, <br /> DISTANCE TO NEAREST: 1 Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> 9 p � Cesspool/seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well li <br /> INTENDED USE TYPE OF WELD <br /> ❑ INDUSTRIAL ❑ CABLE TOOL D,ia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia: of Well.'Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN 'Gauge of•Casing <br /> ❑ IRRIGATION El GRAVEL PACK TDepth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER r Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor All <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter / L.! <br /> Approximate Depth <br /> Describe Material and Procedure g <br /> �sz caw_,• �aI <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." 111 R <br /> ntractor's hirin r sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> p it is issued, hall employ persons subject to workman's compensation laws of California." <br /> I 'it call for rout Inspection prior to grouting and a final inspection. <br /> Signed X , <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date ��� <br /> Additional Comments: <br /> Phase II Gr q Inspection <br /> he li Fi I Inspection <br /> Inspection By date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY 13 PER UMT El PER SITE ❑ EACH ❑ January 1 &Received By Janu ry 31 ❑ July 1 & eceived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE `� � <br /> —I 3 <br /> :LESS <br /> PRORATION <br /> PLUS' i <br /> PENALTY <br /> OTHER, <br /> OTHER <br /> .t S X f <br /> -Received by Date,. - -Receipt No. Permit No. "� Issuance Date Mailed Delivered 1i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - - 1601-E.HAZELTON AVE„P.O.Boi.2GM STOCKTON,CA.95201 <br />