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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: _ APPLICATION <br /> (Far Non-Transferable, Revocable,Suspendable) PUMP&WELL _ <br /> h / <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . 1,_ <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework 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 /> Owner's Name Phone_ar:2 —�0 !;4 <br /> Z <br /> Address -Z"-^:... R City <br /> Contractor's Name '" License# Business Phon <br /> Contractor's AddressT 2t_ <br /> ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �1 <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPEN 11RECONDITION❑ - DESTRUCTION❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ -9 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank c Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION I:1 GRAVEL PACK Depth of Grout Seal " <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP-INSTALLATION: Contractor _� �..a..�-� <br /> Type of Pump e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Don r <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 County <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 /> is issued, l 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 far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I will c to Grout Inspec ion prior to grouting and a final inspection. <br /> t <br /> Signed X ,Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection PhqA IV/nal Inspection e, p/ <br /> Inspection By Date Inspection By Date 73/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By Janua 1 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED C AMOUNT <br /> FEE 7 ,7v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L r <br /> OTHER <br /> OTHER ► <br /> 1 <br /> Received by Date Receipt No. Permit No. Issdance'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 />