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pplicationsWill Be Processed When Submitted Properly Completed. Be Sure To SighTe Application.OFFICE PPLCATION Y <br /> a <br /> f (For Non-Transferable, Revocable, Suspendable) <br /> - - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San oa uin Count Or nce No. 1862 a d th u s and regulations of the San ui Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Owner's Name <br /> Phone <br /> II Address City A <br /> t Contractor's Name City <br /> #'���� Busin Phone �B <br /> Contractor's Addross '�me Phone <br /> Is Certificate of Workman's Compensation Insurance on File SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 91'�DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT❑ , ,� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines*r' Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line-t - -Private-Domestic Well ublic Domestic-Well — - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIALCABLE TOOL Dia. of-Well Ex!tion <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED �"'v <br /> Dia. of Well Ca ' <br /> ❑ D ESTIC/PUBLIC ❑ DRIVEN <br /> a2 Gauge oasi <br /> GRAVEL.P.ACK..., --_--� �--,Depth of Grout <br /> ❑ CATHODIC PROTECTION ❑ Rl}TA'RY ,+•. t `�' <br /> T- sfTy�-6 of Grout <br /> ❑ DISPOSAL s❑ OTHEFt r Other Informat <br /> ❑ GEOPHYSICAL s s Soef Ce Seal InPUMP INSTALLATION: (Contractor ' �.Yp pT e of Purrs .'<-• <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate DepthV ^' <br /> Describe Material and Procedure "F <br /> I hereby certify that I have prepared this application and that the work will be done in accordan a with San Joaquin County L}3 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. .<>- <br /> __' _ <br /> owner or licensed agent's signature certifies the following::`I ceitify that in the performance of th�wark for which thispermit <br /> Home <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws df:California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work to which this <br /> permit is issued, I shall employ p rsons subject to workman's compensation laws of California." <br /> I wits for a Grout Inspec ' rior t grouting and a final insp n. <br /> Signed X • : �T. _ .� _.., s.� . �-- <br /> x�; ��� f <br /> Title:' �Qate tl <br /> r Plot Plan on Reverse Side) <br /> F R DEPA TMENT USE ONLY <br /> PHASE <br /> r <br /> � � p <br /> Application Accepted By Date <br /> Additional Comments: 3` <br />. t x-�. � <br /> Phase II Grout(Inspection �!° P se Final I pectio <br /> �v/ n <br /> Inspection By r date 49-- ( Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ FAC41 Januaryl &Received B Januar <br /> Y Y Y 31 -❑ July 7 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE - g REMIT <br /> ¢ DAT '` ;DATE REMITTED '` AMOUNT DUE CHECKED <br /> ' AMOUNT <br /> FEE r ; <br /> LESS ri_ <br /> PRORATION <br /> i <br /> PLUS <br /> PENALTY <br /> _ S <br /> OTHER <br /> `�! U 7 <br /> Received b - L <br /> - Y ate - Rece}pt No- Permit No- - uan Date Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> _ ;.....bb'- 1601 E.HA2ELTON AVE.,P.O.Bow 2009- STOCKTON,CA 95201 �"'�' 2 <br />