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Applications Will Be Processed When Submitted Properly Completed. Be Sure To'Sign The Application. ,..�. <br /> t� -N9R OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i,. Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ord ina ce No. 1862 an t e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address + v City/Town <br /> Owner's Name Phone <br /> Address City <br /> I <br /> I Contractor's Name rLo /1 License Business Phone [ <br /> fContractor's Address Emergency Phone <br /> f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-J -- No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C3 N-1 <br />' REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank _fid f Sewer Lines + Pit Privy —� <br /> Sewage Disposal Field Cd Cesspool/Seepage Pit Other <br /> II Property Line/Q_ Private Domestic Well,LQ4 Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4 /dDeye <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION 5tROTARY Type of Grout, <br /> ❑ DISPOSAL ❑ OTHER Other Information Sn t ! <br /> ❑ GEOPHYSICAL Surface Seal Installed By: icie, <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: „W��..ell Diameter r Approximate Depth a � <br /> Q ,Describe Material and Procedure G-y�E,, -t.SPsj <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 /> I wi all lora u spe i prior o grouting and a final inspection. <br /> r <br /> Signed X � Title: Dale: <br /> (Draw Plot Plan on Revers ide) <br /> F R DEPAATMENT USE ONLY <br /> PHASE ] <br /> Application Accepted 8y Date �_- r]� <br /> Additional Comments: , —=�J —� <br /> i <br /> sell G out Inspection P III Fin rinspection <br /> Inspection By_, <br /> y Date -- Inspection By Date <br /> 1-7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> F PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES 1601 F.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> n <br />