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ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION µ <br /> (For Non-Transferable, Revocable, Suspendable) <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 fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health_District. <br /> Exact.Site Address �� vCity/Town I—er� <br /> Owner's Name Phone i_, I <br /> Address <br /> City <br /> Contractor's Name ti License# Business Phone <br /> Contractor's Address Emergency Phone ' <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL'❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q�l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ 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 <br /> TYPE OF WELL <br /> ❑ <br /> INDUSTRIALI❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE �'DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC $' <br /> i DRIVEN Gauge of Casing i <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C�j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done LL <br /> DESTRUC ON OF WELL: Well Diameter f <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <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 will call for a r ut Inspectio prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY f <br /> PHASEI I <br /> Application AcceptedBye Date <br /> Additional Comments: <br /> Pjmase II Grout Inspection d� ! P ase III Final Inspection <br /> Inspection B Date f / Inspection B Date IC—qa <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recekved By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASS EXPLANATION DATE DATE HEM TED AMOUNT DUE CHECKED j <br /> Q.� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived Date E Receipt No. Permi[No. Issuance Date Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT]SERVICES - 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br /> y <br />