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Applications Wiil Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> F ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I <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 J20qi,Iin County Ordinanbe 1862 and the rules and regulations of the San J quinliocal Health District. <br /> Exact Site Address ~ ����— City/Town ., <br /> Owner's Name r "'7 Phone �Z <br /> Address '�� - City ; F <br /> Contractor's Name ;., License 446;24 .Buusiness Phone' -� + <br /> Contractor's Address ' Emergency Phone Tec.-6�-,2 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No t <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ T <br /> REPLACEMENT 1`1 \ <br /> DISTANCE TO NEAREST: Septic Tank _• 7 Sewer Lines Pit Privy <br /> Sewage Disposaf Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Weil <br /> r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRLLED . , Dia. of Well Casing i <br /> IC 17_1 <br /> VEN Ga <br /> of Cang <br /> ❑ RR GATIION UBL ,- = - tv ❑ IGRAVEL-PACK;�«..►'—d.,o-.. _-Dep heof.Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY k .Type of Grout f , <br /> ❑ D,ISPOSAL ❑ OTHER I --- "`.,,fOther Information <br /> ❑.GEOPHYSICAL {� Surface Seal Installed By: �} r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` _ H:P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work D no e t <br /> DESTRUCTION OF WELL: Well Diameter tApproxi mate Depth ad I <br /> Describe Material and Procedure " <br /> hereby certify that I have prepared this application and that the work will be done in accorrddari b with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. < <br /> , t <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which his permit <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." f <br /> I w' all 1 r a Grou!jrpOction prior to groutin and a final inspection. <br /> Signed Title: <br /> I Date.. <br /> (Draw Plot Plan on Reverse ide) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> �Z <br /> Application Accepted B Date , <br /> Additional Comments: a <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection B 3 ate <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By Januafy 31 ❑ July 1 &Received By July 31 <br /> BILLING. REMIT4ANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED' AMOUNT <br /> FEE <br /> } <br /> LESS - - -- <br /> PRORATION <br /> PLUS <br /> PENALTY - '"' <br /> OTHER <br /> OTHER - <br /> Received by Date - Receipt No. Permit No. Iss ante D 1e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEfiM1TlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />