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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: a - <br /> t iE FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> F <br /> t (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 County Ord' ante N . 1862a the rules and regulations of the San Joa uin L cal Health District. <br /> I Exact Site Address r City/Town " <br /> Owner's Name Phone <br /> { Address � o <br /> C City <br /> Contractor's Name C r—,— 11 License#jam 7-Z Business Phone �C—�1��� <br /> 4 Contractor's Address # 2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL N' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I <br /> Lf <br /> DISTANCE TO NEAREST; Septic Tank d Sewer Lines Pit Privy <br /> Sewage Disposal Field -5'C! r Cesspool Pit <br /> p Other <br /> Property Linea//1 r Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL —� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> I �4 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing'" <br /> ❑ IRRIGATION ❑ GRAVEL PACK ,, . Depth of,Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: CAJ k e r^ � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> 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. , <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 <br /> y(rkman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the lollowing:"I certify t"t in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. `• �` <br /> Signed X _�7 �_ � _ Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) I <br /> FOR EPA TMEN USE ON Y <br /> PHASE ! t <br /> Application Accepted By Date <br /> Additional Comments: ) <br /> Phase Il Gr ut:lnspection Phase lil Final Inspection <br /> Inspection By Date Inspection By Date — yp <br /> Fee Is Due: ❑ A Y ❑ PER UNIT ICI PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE fy/ <br /> LESS y�( <br /> PRORATION { <br /> PLUS <br /> i PENALTY I <br /> OTHER <br /> OTHER <br /> b4IYswo 3�e s� fin+« _ <br /> Received by - - Date _ Receipt No. Permit No. Issuance 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 />