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Applications Will Be Processed WhenSubmitted Properlycompleteo.ae aure 1o argn Inen}+I+rnauv+ <br /> FOR OFFICE USE: APPLICATION <br /> -- - (For Non-Transierable, Revocable, Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand!orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the tules and r gulatio o the an Joaquin Local Hea th i $. <br /> /x[ 6 r own <br /> Exact Site Address L/ <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name L License#�- Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes, No k <br /> TYPE OF WORK (CHECK): NEW WELL% DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank Sevier Lines Pit Privy <br /> Sewage Disposal Field f Cesspool/Seepage Pit Other <br /> Property Line _ Private D'omestic"Well _.Public Domestic Well y j <br /> INTENDED USE TYPE OF WELL /j�► <br /> k❑ INDUSTRIAL _ `❑ CABLE TOOL Dia. of Well Excavation �i <br /> !�u DOMESTIC/PRIVATE _ ,. �❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN r t Gauge of Casing <br /> ,rd <br /> ❑ <br /> I}u GRAVEL PACK Depth of Grout Seal IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION ,� ROTARY <br />`. ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> H.P. , <br /> Type of Pump ) <br /> PUMP REPLACEMENT: ❑ State Work Done- <br /> PUMP REPAIR: 11 State Work Doq'e. ` <br /> ! <br /> DESTRUCTION OF WELL: Well Diameter ,..- Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby certify that 1 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 foliowing:"I certify that in the performance of the work for which this permit <br /> p is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> j Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Ins tion prior lip grouting and a'final i9ppalion. <br /> Signed X It Date: <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By- � '�''-r' Date D <br /> Additional Comments: <br /> Phase II Grout ns tion Pha a 111 Final Inspection <br /> Inspection By to Inspection By Date <br /> l� Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE <br /> CT ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedRE y July 31 <br /> y BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE <br /> Mo <br /> REMITTED ANT <br /> ' FEE V q.-3L�zr <br /> �i <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> �. OTHER - <br /> _ <br /> ! Received by Date Receipt o- - 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 952 <br />