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—x Applications Will 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 /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) i WATER QUALITY <br /> Application is hereby made to the San JoaquinL ocal Health District fora permit to construct and/or i.nstallthework 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 City/Town <br /> II: <br /> Owner's Name •- Phdne <br /> i <br /> Address - City CIT 2n, <br /> , <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W h SJLHD? Yes, No <br /> TYPE OF WORK {CHECK): NEW WELL rD' DEEPEN ❑ s RECONDITION 11DESTRUCTION❑ <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 Lin ei Private Domestic-Well Public Domestic Well C, , <br /> INTENDED USE '!! TYPE OF WELL �.Jf <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> PA DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑µOTHER ; Other information <br /> ' <br /> El GEOPHYSICAL Surface Seal Installed B <br /> � � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .S ill H.P. <br /> PUMP REPLACEMENT: El State Work Done <br /> PUMP REPAIR: ® State Work Done `" �" I� �1 .. <br /> IM <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 1 <br /> f <br /> I 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 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 /> ersons subject to AL workman's compensation laws of California." <br /> permit is issued, I shall employ(p <br /> I wit call for a4rout Inspect' p for o 1i and a final inspection. <br /> Signed X a itle: Date: <br /> ;I (Draw Plot Ian on Reverse Side) <br /> � 1 <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE I �-P-h <br /> pateApplication Accepted By Additional CommentsP ase 11 Grout Inspection s r ->-_- ase 111 anal Inspection <br /> Inspection By - W Date Inspection By T �Date <br /> I <br /> Fee;Is Due: ❑ ANNUALLY []'PER LNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION III <br /> PLUS I� <br /> PENALTY <br /> ' OTHER <br /> OTHER ' <br /> 15- <br /> Received by Date Receipt No Permit No.•Y Issual Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: �'ENVIRONMENTAL HEALTH PERMITISERVI CES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />