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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) WATER QUALITY �� <br /> I 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 CoVk <br /> ty Ordinance No. 862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address +_ City/Town <br /> Owner's Name Phone ,�i <br /> Address U A9 <br /> City <br /> Contractor's NameLicense# Business PhoneSf� <br /> Contractor's Address a t Emergency Phone w <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El ' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field . _ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE j TYPE OF WELL <br /> 111❑ <br /> INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation <br /> ,uOMESTIC/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 r'1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> _. Typeiof Pump- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: well Diameter Approximate Depth {� ' <br /> M "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-Healih bistrict ` <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 wbrkman's compensation laws of California." Q <br /> Contractor's hiring or sub-contracting signature certifies the following:A certify that ih the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of�California." y <br /> I will c a Grout Inspection,prior to grouting and a final inspection. <br /> Signed X f Title: I <br /> Date: 3 <br /> 1 (Draw Plot Plan on Reverse Side) <br /> l I <br /> s <br /> FOR DIIEPARTMENJUSE ONLY <br /> PHASE } <br /> Application Accepted By ( Date �� o <br /> Additional Comments: l <br /> - Phase II Grout Inspection Phase III Final Inspection t <br /> i Inspection By tf Date Inspection Byl Date 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ JuEy 1 &Received By July 31 <br /> REMIT. <br /> BASE EXPLANATION <br /> BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE — <br /> LESS i ',7 }jR <br /> PRORATION <br /> I PLUS i <br /> PENALTY r <br /> i _ - <br /> OTHER <br /> OTHER <br /> '-.,,Receivetl by Dale R Receipt No`="' -�- -Permit No - - Issuance Date - Mailed i ered <br /> � APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bo.2009 ST CKTON,CA- <br />