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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r' FOR-O :CE USE: <br /> _ _ APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> k ENVIFONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to theSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described. This application is <br /> made in compliance with San J in County r inanc o 1862 and les and re ns of the San Joa u;n Loca�e Ith District. <br /> Exact Site Address City/Town <br /> r ' <br /> Owner's Name / /� / Phone <br /> Address City <br /> Contractor's Name ense# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensationflnsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge Of Casing - - <br /> E <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL Surface Seal I By: <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 /> 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. <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." <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 wfor tion-prior to grouting and a final inspection. <br /> Signed i <br /> e: Date: <br /> ;" (Draw Plot Plan an Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: ' <br /> Phase II Grout tIns Inspection ; <br /> P se !II Final Inspection <br /> Inspection By Date Inspection By Date 7 <br /> Fee Is Due: ❑ 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 TDUE Y AMOUNHECKED <br /> � DATE DATE REMITTED C <br /> u� AMOUNT <br /> FEE � s � �? <br /> J LESS <br />'s PRORATION ??? <br /> i <br /> x PLUS d <br />` PENALTY <br /> OTHER # <br /> OTHER <br /> #� <br /> Received by Date y Receipt No, Permit No. Issuance Date Maifed Delivered <br /> `tiPPLICANT—RETURN ALL COP1E$TO:.. E14VIRONMENTAL-HEALTH PERMIT/sERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952p11. <br /> -��=is- <br />