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_ Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. • <br /> FOR OFFICE USE: APPLICATION - <br /> r. (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ` <br /> Aaplication is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance wi an Joaquin C ty Ordina e o. 1882 and a•rules and regulations of the San Joan ILoca alth District. <br /> Exact Site Address f City/Town <br /> a <br /> Owner's Name /r/'i r//� _-Phone <br /> Address City _ <br /> Contractor's Name Licenseusiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK: NEW WELL M-'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 'o' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®ate PUMP REPAIR❑ 0 1` <br /> REPLACEMENT❑ <br /> I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines C560 '' <br /> Pit Privy ml'_ <br /> Sewage Disposal Field Cesspool/Seepage Pit /-P e9 If` Other too 9W° <br /> ,,Property Line Private Domestic Well Public Domestic Well �Q r� <br />{ INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation .12- <br /> ❑,.,,, <br /> DOMESTIC/PRIVATE M'UF{ILLED Dia. of Well Casing <br /> W—DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Y' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal p{�, <br /> ❑ CATHODIC PROTECTION W`i�OTARY I Type of Grout eF <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> k <br /> El GEOPHYSICAL Surface Seal Instal d By: <br /> PUMP INSTALLATION: Contractor `_� <br /> Type of Pump l %F H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f PUMP REPAIR: ❑ Slate 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 /> i I <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 compensation laws of California." <br /> I t a ra �!Lction-prior to grouting and a sinal inspection. / <br /> Signed Title: r Date: <br /> (Draw Plot Plan on Reverse idey- <br /> F RDEPARTME USE ONLY <br /> PHASE f <br /> Application Accepted By— <br /> Date <br /> Date <br /> Additional Comments: <br /> hase II rout Inspection / C a eAll FiM I Inspection - <br /> Inspection By Date t7 !O 0 Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑.EACH ❑ January 1 &Received By January 31 ❑,July 1 &RecLived BXJLLL 31 <br /> r .r• RE IT <br /> BASE '. EXPLANATION BILLING REMITTANCE .., $ r AkOUNT DUE CHEC ED <br /> I a t DATE DATL "" r_ REMITTED: !AMO NT. <br /> FEE - <br /> LESS <br /> PRORATION <br /> t PPLUS <br /> ENALTY <br /> OTHER <br /> i <br /> OTHER <br /> , <br /> , <br /> Received by Date Receipt No Permit No. . Is uan Date- Mailed Defivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1.601 E.HAZE LTG NA,VE.,P.O.Box 2009 STOCKTON,CA 95261 <br />