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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TV Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) / PUMP&WELL <br /> ENVIRONMENTALHEALTH PERMIT r i / ,� � <br /> a- i —1 �"T <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work heMindescrideed.This applicati Is <br /> made in compliance wit anoaq n County Ordinance No.1862 _,—and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address l� .s 4 Vern SV44 City/Town" <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Ath SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO6-----'PUMP <br /> ,N.❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION ter PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 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 /> �03, ISTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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 Surface-Zeal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR- ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> el <br /> 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit G <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 r a Grout Ins prior to grouting and a final inspection. <br /> Signed Title: Date: <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted By Date �� <br /> Additional Comments: <br /> Phase II Grout Inspection Isere I'll Fin n "tion <br /> Inspection By _ Date _ Inspection By Date <br /> Fee Is'Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - 'EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED' AMOUNT <br /> FEE <br /> LESS Y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER q f <br /> ! 7 <br /> Received by Date Receipt No. Permit No. I suanc 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 /> r <br />