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Applications Will Be Processed Whenbuomil[ea rropeny �umlilI. ... w- _•1•• <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> S. <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 /> made in compliance with an Joaquin County Ord' e No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name �zP-�f ► g' Phone 5-Q S <br /> -� City <br /> Address r/ <br /> Contractor's Name License#3 Business Phone �7 — <br /> Contractor's Address I iC311SdL�J N' j��Mmergeracy Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit~S JLHD? Yes No �f <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &"" 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 /> ❑_ 1 �STRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> fS Q ) <br /> AP-PRtVATE ❑ 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 /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - V 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 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:"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 /> perrait is issued, I shall employ persons spbject to workman's compensation laws of California." <br /> I ill call fora rut Inspe io riar t grouting and a final insp ion. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I �p <br /> Application Accepted By Date <br /> Additional Comments: -3 <br /> Phase li Grout InspectionPhase III Final Inspection <br /> Inspection By Date <br /> Ins aon By Date ��0, <br /> Fee Is Due: ❑ ANNUALLY 1] PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv d By REM1Tuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> Y ✓ <br /> { LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. ermi No. Issuance Date Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />