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ppRcauonswill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATIONa, <br /> (Far Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENT4.L HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) ., ATER W3"�' QUALITY <br /> Application is hereby madetothesan- aquinLocalHealth District fora permit to construct and/or install the work herein d <br /> made in compliance escribed.This application is <br /> . <br /> Exact Site Address Cyt Sa Joaq ¢ rdinance No1 62 and the rules and reg lati l oth n Joaquin Local Health District. �y <br /> �` <br /> r o n <br /> Owner's Name � <br /> Address Phone <br /> Contractor's Name <br /> City <br /> r License#LSc /S[ Business Phone t <br /> _ <br /> Contractor's Address <br /> - J <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL No e <br /> DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 111 <br /> REPLACEMENT❑ PUMP REPAIR❑ I <br /> DISTANCE TO NEAREST: Septic Tank Q i <br /> �4 _ Sewer Lines -"-_ <br /> Pit Privy <br /> Sewage Disposal Field � Cesspool/Seepage � <br /> eepage Pit Other + <br /> Property Line 04 Private Domestic Well_�Q_ Public Domestic Well y� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOLDiaExcavation- <br /> DOMESTIC/PRIVATE <br /> DOMESTIC/PRIVATE 13 DRILLED . of Well Excavation <br /> Dia. of Well Casing ii ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION r,� Gauge of Casing <br /> la GRAVEL PACK Depth of Grout Seal r l <br /> ❑ CATHODIC PROTECTION ,� ROTARY <br /> 11 DISPOSAL TYpe of Gfout <br /> ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed 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 <br /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 II for a t spec ' n rior to grouting and a final inspection. 1 <br /> Signed X <br /> Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Si <br /> OR EPARTM T USE ONLY, <br /> PHASE I <br /> Application Accepted By— <br /> Additional <br /> y Additional Comments: <br /> Date <br /> e II Grout Inspection Phase Ill Final Inspection <br /> Inspection Date Inspection By Date <br /> Fee Is Due: 1:1NNUALLY PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 t <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT i <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> ' <br /> LESS 1� I <br /> PRORATION <br /> PLUS <br /> PENALTY �' S <br /> OTHER # <br /> OTHER <br /> Received by Date Receipt No. 4�.,permit No Issuanc Date <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE IVR CES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,C <br />