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Applications Will Be Processed When Submitted Property Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joauin County Ord' an No. 18 a d the.rules and regulations of the San Joaquin L c 1 Health District. <br /> Exact Site Address i City/Town —5 <br /> Owner's Name Phone <br /> Address _ City <br /> Contractor's Name cense# ,2?-�!/ Business Phone <br />_ Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELLA DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> f <br /> DISTANCE TO NEAREST: Septic Tank 5elnrer Lines Pit Privy <br /> Sewage Disposal Field_ !3 / Cesspool/Seepage Pit Other <br /> Property Line 1, Private Domestic Well $4. 4 Public Domestic Well <br /> INTENDED USE TYPE OF WELL // <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ,I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC 1:1DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ,. <br /> ❑ CATHODIC PROTECTION krROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 's <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor v <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 CountyI <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 riot employ any person in such manner as to become subject to workman's compensation laws of California." j <br /> Contractor's hiring or sub-contractin at re certifies the following:"I certify that in the performance of the work for which this -. <br /> permit is issued, I hall mploy per ns subject to workman's compensation laws of California." <br /> 1 I I for a ut pecti routing and a final inspection. f <br /> Title: <br /> Signed X a AJDate: 8 <br /> (Draw Plot Plan on Reverisi <br /> FO DEPARTMENT USE ONL <br /> PHASE 1 � C (� <br /> Application Accepted By Dale O <br /> Additional Comments: y <br /> Phase 11-Grout Inspection �r �] Phase III Final Inspection <br /> Inspection By _ K� Date- b Z + Inspection By Date <br /> Fee Is Due: 11 ANNUALLY - ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &fReceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING .REMITTANCE $ AMOUNT DUE CHECKED <br /> 1�`y`� DATE DATE REMITTED AMOUNT <br /> PLIFEE '- 4�J _ � <br /> RLESS PRORATION ��-(� r4 i/ Zr F�4�� L <br /> PLUS ✓G!� S-0 .4 1 <br /> ` <br /> PENALTYpv{ <br /> L OTHER by <br /> Receipt o. Permit No, ssuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P-O,Box 2009 STOCKTON,CA 95201 <br />