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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: a/ APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> it ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPETE IN TRIPLICA E) WATER QUALITY <br />"A�'Applicatioh is hereby madeto he San'Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br />-remade tri compliance with San Joaquin County Ordinanc No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Sitf;iAddress _ . .�� �_ � � City/Town <br /> Owner's Name Phone <br /> Address /11 _ City <br /> Contractor's Name ' License# Business Phone_ SS�S1/ i <br /> Contractor's Address Emergency Phone 4` S-�a7f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ C� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El 'J <br /> REPLACEMENT❑ Ii �� e <br /> DISTANCE TO NEAREST: Septic Tank _ /Q(�..__ Sewer Lines Pit Privy - <br /> Sewa a Disposal Field <br /> —__/,o <br /> p _.._�0� Cesspool/Seepage Pit Other 7�: <br /> Property Line Private Domestic WellPublic Domestic Well <br /> A" { <br /> INTENDED USE ;I TYPE OF WELL — <br /> ❑ INDUSTRIAL © CABLE TOOL Dia. of Well Excavation _ <br /> i <br /> ,DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing 96 'O ! <br /> © DOMESTIC/PUBLIC �: ❑ DRIVEN Gauge of Casing GLlej <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �� ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL j Surface Seal Installed By: <br /> PUMP INSTALLATION: i9 Contractor <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: ii ❑ State Work Done <br /> PUMP REPAIR: 'I ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i� 1 <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, arid 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, 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." <br /> I will all for a Grout Inspect' n prior to grouting and a final inspection. <br /> Signed XI-12QTitle: Date: <br /> ( aw Plot Plan on Reverse Side) <br /> .I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k <br /> Application Accepted ByDate <br /> Additional Comments: i <br /> — - <br /> i. <br /> Phre I rout Inspection Phase III F' al Inspection <br /> Inspection ByM Pt_ Date P13 Inspection By Date p <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> II BILLING REMITTANCE $ <br /> REMIT <br /> BASE li EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C`j� �3 �� a 44 <br /> ~ <br /> LESS '! <br /> PRORATION P <br /> PLUS Ai t <br /> PENALTY <br /> OTHER n <br /> OTHER it <br /> 2aa� M <br /> Received by Date IJ Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 <br /> a , <br />