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= Applications Will Be Processed When Submitted ProperlyCompleted. ae sure iosign ineAppnvacran. 'f "/ - <br /> FOR O ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) r. <br /> PUMP&WELL _ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an <br /> install the work herein described.This application is <br /> made in compliance with San Joaquin Cou,2W Ordinance No. 1 nd the rules and regulations of the Sajl JgpquinLocgI Health District. <br /> Exact Site Address City/Tow;ws_ w--r MW <br /> Owner's,Name t/rI" 1V� Phone <br /> Address City <br /> Contractor's Name ' License#IBusiness Phone <br /> Contractor's Addres ! ency Phone <br /> Is Certificate of Workman's CompensationInsur nce on File With SJLHD? Yes No {� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION El 'V <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ C> . <br /> REPLACEMENTO01 1 <br /> DISTANCE TO NEAREST: Septic Tank � r51 or Lines Pit Privy <br /> Sewage Disposal Field t Cesspool/Seepage Pit Other <br /> Property Lin Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 UAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Q0 <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 /> 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 workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 w' all for a o pection prior to grouting and a final inspection. <br /> r <br /> Signed X Title: Date: <br /> / (Draw Plot Plan on Re se Side) ' <br /> FORD PARTME T USE ONLY <br /> PHASE <br /> Application Accepted By ,7t Date d <br /> Additional Comments: <br /> Phase 11 Grout Inspection P II Final nspectian <br /> Inspection By Date Inspection ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY. <br /> OTHER <br /> OTHER <br /> 2 2� <br /> Received by Date Receipt No� Permit No. ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STDCKTON,CA 45201 <br />