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-- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: t APPLICATION <br /> *J 3 (For Non�Transterable, Revocable,Suspendable) <br /> � PUMP&WELL <br /> ENVIR©NMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> r (QOMPLETE IN TRIPLICATE) <br /> E Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin C unty Ordinance No. 1862 and the rules and regulations of the San Jo.Auin Local Health District. <br /> E,act Site Address City/Town C <br /> Owner's Name Phone J <br /> Address "t �" 1 City <br /> L Contractor's Name Lice a#/ - Business Phone. <br /> Contractor's Address - Emergency <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ 'DEEPEN ElRECONDITION Ph DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI5b� ` <br /> [ REPLACEMENT❑ 1 _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _ <br /> Sewage Disposal Field Cesspool/Seepage Pitf Other <br /> Property Line _ Private Domestic Well Public Domestic Well x <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 /> i Type of Pump _ H.P. y <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:1 certify that in the performance of the work for which this permit <br /> f 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 will call for a Grout Inspection prior to grouting and a final inspect' / f <br /> Signed X471 , Title: �l/l9-4�fOd�J�l�i, Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE AX� �J <br /> Application Accepted By �- Date. <br /> Additional Comments: <br /> Phase 11 Grout Inspection ir., Fi ai I n <br /> Inspection By Date Inspection B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan- ryIReceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING - -REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED' <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE _� u <br /> LESS <br /> L PRORATSON a <br /> PLUS 'SISC190 <br /> PENALTY <br /> OTHER <br /> t OTHER <br /> Received by Date - Receipt No-, PerAFNIo. Issuance Date Mailed Wivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box2009STOCKTON, <br />