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..aavni will eyeProcessedWhen Submitted Property Comple I h— � -s <br /> Fi OFFICE USE; „ic - <br /> ed: Be Sure To Sign The Appfication.� i-�-- <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 /> I made in coml5liance with San Joaquin County Ordinance <br /> Exact Site Address o. District. <br /> t 2 and the rules and regulations of the San Joaquin Local Health1 <br /> _ y� <br /> Owner's Name II ' City/Town <br /> Address ` y Phone <br /> Contractor's Name " City <br /> Contractor's Address License# Business Phone <br /> Emergency Phone <br /> Is Certificate Of Workman's Compensation In urance on File With SJLHD? <br /> TYPE OF WORT( (CHECK}; NEW WELL DEEPEN ❑ Yes ` No <br /> WELL CHLORINATION ❑ WALL ABANDONMENT ❑ RECONDITION❑ DESTRUCTION❑ O� . <br /> REPLACEMENT❑. OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 i <br /> DISTANCE TO NEAREST: Sepic Tank s (11 <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field lid <br /> Cesspool/Seepage Pit <br /> INTENDED USE <br /> Property Line Private Domestic Well Domestic Well Other <br /> Public : <br />' ElINDUSTRIAL ❑ CABLETYPE ELL <br /> r/ <br /> +*! <br /> DOMESTIC/PRIVATE I Dia. of Well Excavation <br /> ElDOMESTIC/PUBLIC ❑ DRILLED❑ DRIVEN �Dia. of Well Casing <br /> El <br /> Gauge of Casing410, <br /> ❑ CATHODIC PROTECTION GRAVEL PACK Depth of Grout Seal / <br /> El DISPOSAL ROTARY Type of Grout Q <br /> ❑ GEOPHYSICAL OTHER Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor <br /> PUMP REPLACEMENT: I Type of Pump <br /> ❑ State Work Done H.P. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter r <br /> Describe Material and Procedure Approximate Depth f <br /> o <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, aril 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, f shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> c <br /> Contractor's hiring or sub- ontractPn9nature si certifies the following: <br /> m l0 g 9="I certify that in the performance of the work forwhich this <br /> permit is issued, I shall e <br /> P y persons subject to workman's compensation laws of California." <br /> I wi call for a Grout Inspe n prior to groutin and a final inspection. <br /> Signed X Imp jr,P <br /> Title: f �i <br /> j <br /> (Draw t Plan on Reverse Side) Date: <br /> I` FOR DEPARTMENT USE ONLY. <br /> PHASE I ry <br /> Application Accepted By (t.h�J�gi <br /> Additional Comments: Dates r <br /> .;i <br /> Ph se I rout Inspection <br /> Inspection B' 1 r' ,� r Phase III Final Inspection <br /> Date7 Inspection By <br /> Date <br /> Fee Is Due: ❑ <br /> ANNUALLY PER UNIT ❑ PER SITE <br /> 13 EACH <br /> ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER <br /> { <br /> Received by 1r� Date + 1 3 <br /> I� Recaipt No. Permit No. t <br /> APPLICANT—RETURN ALL COPIES TO:11 ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance pate Mailed Delevered <br /> .. as T - ES 1601 E,HAZELTON AVE.,P.O.12009 STOCKTON,CA 95201 <br />