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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F6Fi-j0FFi E'USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ' —(� <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permittoconst uctand/or install thework herein described.This application is <br /> made in compliance with San Joaquin Co My Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ., � City/Town <br /> Owner's Name IP a Phone _ � _�� � / <br /> Address City <br /> Contractor's Nam' Q <br /> License'#,_93W0_(_ Business Phone <br /> Contractor's Address C� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WithJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,.N D <br /> 1:1d` <br /> WELL CHLORINATION WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION t PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ Ir>DdSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ER'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout u <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL fi SurfaceSeal Installed By: <br /> PUMP INSTALLATION: con tractoSP <br /> r <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 11 State Work Done Nt <br /> PUMP REPAIR: 13 State Work Done r <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 i <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 parr r Grout n ction prior to grouting and a final inspection. <br /> Signe ^# <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �lJ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ri Phase III Final Inspection <br /> Inspection By Date Inspection By Date, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 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 /> PLUS <br /> PENALTY <br /> OTHER / <br /> OTHER f <br /> A(-3$-g o <br /> e' <br /> Received by Date Receipt No. Permit No. - Issuance Date Mailed ivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />