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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOROFFICE USE: APPLICATION <br /> (For Nan-Translerable, Revocable,Suspendable) PUMP&WELL l <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . -4 <br /> Application is hereby madeto the San Joaquin Local Health District for•a.permitto construct and/or insta the wok hereinjdescribed.This application is <br /> made in compliance with an Joaquin Coun Ordinan No. 1862-and the rules d re A S tla7 �c eal Health District.. <br /> Exact Site Address ��,, / ' City/Town <br /> I <br /> Owner's Name `� Phone <br /> City J }_ <br /> Address �-,s-� _ �� - <br /> Contractor's Name 7jense#�giP� f- Business Phone (c77 f <br /> Contractor's Address i Emergency PhoneZf— Q Y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes lo?g No <br /> TYPE OF WORK (CHECK): NEW WELL❑ ' DEEPEN ❑ RECONDITION❑­ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP WSTALLATIOPUMP REPAIR �n-t <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> } <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/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 <br /> ❑ GEOPHYSICAL ^ w Surface-Seal-installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �. <br /> PUMP REPLACEMENT: 11 state Work Done H.P. <br /> PUMP REPAIR: ❑ State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure " I <br /> I hereby certify that I have prepared this application-and-that-the.work,"will be'done in accrt oro dance with San Joaquin County ' <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 of the work for 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." y <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, 1 shall employ persons subject to workman.s_compens tion laws of California." <br /> I will r a Grout I spectfolt'Qrior tog !in tj d a final inspe <br /> I ned X t �/' (fitle: -{ Date: <br /> Signed T f ' <br /> (Draw Plot Plan on Reverse Side) <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �.-r-. ,..r.a..-". ��....-�--._-�.---• �/f/�� � ��D' � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection - ���P'h Final Inspection <br /> Inspection By Date Inspection By/' rt Date <br /> Fee Is Due: ❑ ANNUALLV�_[] PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED f <br /> DATE DATE REMITTED t AMOUNT y <br /> II ; <br /> FEE ' <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY r <br /> OTHER <br /> i <br /> F <br /> OTHER / <br /> �3 I� Z5 <br /> Received by Date. * Receipt No. Permit No, Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />