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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureTo SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> a t (Far Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> s <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordi ance No. 1862 and the rules and regulations of the San Joaquin ocai FJealth District. <br /> Exact Site Address City/Town <br /> Owner's Name - rye Phone <br /> Address � City <br /> Contractor's Name - 2�;"AtJ <br /> License#..��-?�usiness Phone '6rContractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? - Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 15 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�I 1 <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 /> r <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 N <br /> ❑ GEOPHYSICAL C^ Surface Seal Install d By: <br /> PUMP INSTALLATION: Contractor e.- H P �� ti <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done e <br /> PUMP REPAIR: State Work Done e& r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ! <br /> Describe Material and Procedure <br /> v t <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 /> Home owner or licensed:agent's signature certifies the following:1 certify that in the performanceof thework 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I w I call-for a Grout Inspe nil for g uting and a final inspection. <br /> Signed Title: an&l Date: <br /> (Draw Plot Ian on Reverse Side) -) <br /> FO DEPA MENT USE ONLY <br /> PHASEI: � <br /> Application Accepted By ?" "'� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection hake 11 F f Ins eclion <br /> inspedtion By Date InspIct <br /> on By Date �� i+ <br /> Fee Is Due: 13 ANNUALLY PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 1 <br /> REMIT <br /> BILLING REMITTANCE $ r <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> l a FEE S �� <br /> LESS <br /> PRORATION,. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -z, (7d <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Delivered i <br /> I -APPLICANT—RETURN ALL.COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />