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ij Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 6PFtCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 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 Or ;finance No. 18U and the'rules and regulationsof the an Joaquin Local Health District. <br /> Si?: w. _� , CitT <br /> / own <br /> Exact te Fkddress y ~ , <br /> 01 <br /> Owner's',Nam y-- - "' ` Phbne <br /> Address'lCity <br /> Contractor's Name i License#cB f Business Phone'l- ' <br /> Contractor's Address 3 ` q Emergency Phone 'Y .,-., <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes No 01 <br /> TYPE-OF WORK (CHECK): NEW WELL❑ DEEPEN'❑ RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION V�J_-- PUMP REPAIR t <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> II Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property line Private Domestic Well Public Domestic Well <br /> INTitNDED USE TYPE OF WELL <br /> ❑ I_N USTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> QDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC .I1 ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 2 Surface Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> y - . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> II I hereby certify that:l have prepared this application and that the work will b�e•done in accordance with San Joaquin County <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 thework forwhich 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 orsub-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 /> r ! wit 6116r Grout ins ction prior to grouting and a final inspection. <br /> Signed — =L—z . 0 Title: Date: r <br /> I I (Draw Plot Plan on Reverse Side) <br /> I€ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ADatepplication Accepted By �! <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se I inal Inspection <br /> Inspection By Date . Inspection B . e Date �O <br /> i <br /> Fyee'ls'Due: ❑ ANNUALLY - -❑ PER UNIT - - -❑ PER SITE' -❑ EACH1Y - ❑ January 1$Received By January 31 ❑ July 1 d Received By-July'31 <br /> �! <br /> REMIT <br /> BILLING _REMITTANCE $ <br /> r BASE EXPLANATION' AMOUNT DUE CHECKED <br /> � DATE DATE REMITTED AMOUNT <br /> . <br /> F.EE <br /> LESS a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> P <br /> OTHER <br /> r <br /> Received by _ Date. x Receipt No. Permit No. Issuance Date Mailed Delivered <br /> II.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />