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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 PUMA&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby madetothe San Joaquin Local Health Districtfora permit-toconstruct and/or install thework herein described.This application is <br /> made in compliance wi h San Joaquin CD f ty Ordinance N 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address <br /> City _ <br /> Contractor's Name A License Business Phone f <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compe sation Insurance on File W h SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ `(1 <br />! WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 114% <br /> i <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 TYPE OF WELL <br /> ❑J INVUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ' <br /> 9 '15OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ,1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 4 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> PUMP REPLACEMENT: State Work Don t <br /> PUMP REPAIR: 0 State Work Done .�l <br /> DESTRUCTION OF WELL: Well Diameterl <br /> �- Approximate Depth j <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. F_ <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for <br /> 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 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 ill a Grout Ins ectiDn prior to grouting and a final inspection. O <br /> Signe Title: — ��-t.` _ Date: 6, <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI O <br /> Application Accepted By 6wg') <br /> Date <br /> Additional Comments: I <br /> Phase 11 Grout Inspection Phase 111 Final Inspection r <br /> Inspection By---------L- Date Inspection By ;Date <br /> I <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATIONPLUS <br /> .. <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> f <br /> Received by Date Receipt No. Permit No Issuance Date Mailed etivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />