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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J <br /> Application is hereby madeto the San Joa uin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wi n Joaquin u t. ;Or in No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addresses City/Town <br /> A I <br /> Owner's Name r. A � ` 1 � Phone <br /> Address City <br /> Contractor's Name ,& r ' License#. 9/`/� Business Phone_ J^O� fl� <br /> Contractor's Address . �V rw Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION.K <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ `r <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 /> l <br /> INTENDED USE TYPE OF WELL ) <br /> ❑ INDUSTRIAL ❑ 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 Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure C/RAJ 6 Sy i!!ewJC r.7_,v� <br /> f— <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:A 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 'I1 call for a Grout Inspection prior to grouting and a final in sp tion. J <br /> Signed X Title: Qom+/ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY } <br /> PHASE 1 Q-�� C1;L <br /> Application Accepted By `'� 4� Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a III Final Inspection,'. <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑3 July 1 R Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �d <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009' STOCKTON.CA 95201 <br />