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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 /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County rdinance No. 18 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -�A c� >' City/Town 0-°CX,,C� <br /> Owner's Name Phone .�I � <br /> Address PWL City <br /> Contractor's Name License ft_� �af Business Phone '3� — � <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No p� + <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ t <br /> REPLACEMENT❑ 4 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy `^ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �►) <br /> 4 Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑� 1�N�STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIV,EN Gauge of Casing ! S <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> t t 111 <br /> ❑ DISPOSAL 13 OTHER Other Information ry <br /> ❑ GEOPHYSICAL Surfa a Seal Installed By: 1 N <br /> PUMP INSTALLATION: (.Contractor <br /> J -`T _ I <br /> ype of Pump H.P',/ ;-Z <br /> PUMP REPLACEMENT: f ❑ State Work Done <br /> PUMP REPAIR: ` n ❑ State Work Done j r <br /> DESTRUCTION OF WELL: r` Well Diameter Approximate-Depth t1 f <br /> y Describe Material and Procedure _ r <br /> ti 1 hereby certify that I have prepared this application and that the work will be done in"accordance-with San Joaquin County <br /> a <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 ofIthework forwhich this permit <br /> is issued, I shall not employ anyi 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 forwhich this p c. <br /> permit is issued, I shall employ(,persons subject to workman's compensation laws of California." t <br /> k Icall t a Grout Ins ctipnt prior to grouting and a final inspection. <br /> -. ..�...�..�..�.�,T- � <br /> Signe t Title:�-c.c�t.+-c-; "Dale: � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> Application Accepted By - Date <br /> Additional Comments: }^ <br /> j <br /> Phased] Grout Inspectionh III Final Inspection <br /> Inspection By Date Inspection By. Date <br /> 1 <br /> -Fee Is Due: ❑ ANNUALLY { ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1.&ReceivedByJanuary 31 ❑ July 1 &Received By July 31 j <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REWTTE� AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br />` LESS <br /> PRORATION <br /> PLUS <br />�`. PENALTY _ <br /> i <br /> OTHER <br /> OTHER -4 <br /> I <br />` <br /> —Received by Date 1 Receipt No. Permit No issuance Date Mailed Delivered <br /> y;-. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES y 1601 E.HAZELTON AVE.,P.O.Box 2009 _ STOCKTON,CA 95201 ' y <br />