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rt <br /> �,ucations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �OFEr (Far Non-Transferable, Revocable,Suspendable) <br /> f^Q�F PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br />/�',.(COMPLET€ IN T-RIPLICATE) � 5� <br /> r Application is hereby rnl the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance w' -San Joaquin County Ordinance No. 1862 alad the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's NamePhone <br /> Address I a City <br /> Contractor's Name License#i�'�. 0 Business Phone <br /> ri <br /> Contractor's Address .� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi! SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION b- PUMP REPAIR❑ <br /> i 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 /> ❑ I USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE "` -❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ 1GRAVEL PACK Depth of Grout Seal } <br />` ❑-CATHODIC PROTECTION ❑!`ROTARY Type of Grout <br /> ❑ DISPOSAL ❑'OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 'Type of Pump H.P.—[ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR: }❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth a <br /> z i Describe Material-arid'Procedure!' <br /> L 5 <br /> �I"hereby certify that I'have'piepared 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 SanJoaquin Lbcal Health District. <br /> ✓ <br /> Homeowner or licensed agent's signature certifies the following:"I certifytthat in the performance of the work for which this permit nr� <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 for which this <br /> .permit is issued, I shall employ persons subject to workman's compensa(ion laws of California." <br /> 's <br /> I w' ca f Grout Inspection prior to grouting and a final inspection. ! <br /> i .J <br /> Signe Title: I = ""s Datej�1 0•� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT,USE ONLY <br /> /PHASEI : <br /> f i <br /> - � -311,;h� <br /> Application Accept-- Date <br /> € <br /> Additional Comments: ,` <br /> t <br /> pect ion <br /> P a al Inspection <br /> InspectionBy Date "' - Inspection By Date <br /> �[rd <br /> Fee Is Due: ❑ ANNUALLY 1 ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ 3a6uary 1 &Received By January 31 '❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION!' Y AMOUNT DVE CHECKED <br /> DATE DATE t REMITTED AMOUNT , <br /> FEE <br /> LESS <br /> ' PRORATION <br /> PLUS r� <br /> PENALTY <br /> OTHER <br /> .. <br /> OTHER <br /> .Received by Date 1- Receipt No. Permit No. lissuaribe Date - Mailed - Der red <br /> APPS ANT--RETURN ALL COPIES TO: i ENVIRONMENTAL HEALTH PERM ITISERYICES 1601 E.HAZELTON AVE.,P.O.Boy 2004 5T KTON,CA 952 <br />