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Applications Will Be Processed Wher�Su6mitted Properly Completed. Be Sure To Sign The Application. r <br /> Fo ICt-USE: APPOCAT,ION z t. <br /> x (For Non-T ansferable, Revocable, Suspendable) / PUMP-&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY t <br /> (COMPLETE IN TRIPLICATE) 4�, <br /> ffictforapermittoconstructand/orinstalitheworkhereindescribed.Thisapplicationis <br /> Application is hereby made to the San Joaquin Local Health Dis <br /> t <br /> made in compliance with San aquin Count rdinan a No,188662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Y �- •• City/Town 1 <br /> 1a <br /> Phonf <br /> •?;' e - <br /> Owrier's Name <br /> City <br /> Address• 0License#3 Busine`s1. Phone y <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address _ X �'h �'_ t <br /> I is Certificate of Workman's Compensation lnsurance_on File With SJLHD?: Yes ` j No <br /> TYPE OF WORK (CHECK):` NEW WELL❑~ Y DEEPEN ❑ RECONDITION❑ rDESTRUCTIO,N.❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑" PUMP .INSTALLATION L . PUMP REPAIR❑ l <br /> . REPLACEMENT❑ a- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> N Sewage Disposal Field Cesspool/Seepage Pit:' Other <br />` Property Line Private Domestic Well _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND�ISTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ©1OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractors <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT:... State:Wank Done' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' f , <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 /> } <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> ' mance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the perfor <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for' Grout Inspection prior to grouting and a final inspection. <br /> z <br /> Signed X Title: Date: <br /> .• (Draw Plot Plan an Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted B.y— Date <br /> Additional Comments:_ <br /> j�I7 <br /> Phase 11 Grout Inspection hasapection <br /> Inspec B Date <br /> -•Inspection By Date P y / <br /> ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By=January 31 { ❑ July 1 &Received By July 31 <br /> Fee Is Due' ❑ REMIT <br /> n BILLING + REMITTANCE $ �"d" AMOUNT DUE CHECKED <br /> ' Y4 BASE EXPLANATION DATE DATE REMITTED AMOUNT- <br /> - <br /> FEE <br /> . <br /> LESS , .. <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER '. r <br /> i. t - <br /> f 1r. <br /> Received b Date- Receipt No. Permit No. Is anc to Mailed Delivered <br /> 9: <br /> APPLiCAN.4 RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />