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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .,FOR O'ffICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit Sa Joaquin County Ordin ce N 1862 and the rules and regulations of the San Joaq_uiryLcaf Health District. <br /> Exact Site Address ^ ' �'� City/Town 3�0 "e <br /> i <br /> Owner's Name Phone <br /> Address Z City <br /> Contractor's Name S License Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <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 OtherY <br /> Property Line (/_"Sa,7L--Private Domestic Well Nadl� Public Domestic Well <br /> INTENDED USE TYPE OF WELL { <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation y[ # <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing A <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f <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 /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure i <br /> I hereby certify that I have prepared this application and thatthework will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. [) /n Vin,t< /,/I )&d I <br /> Home owner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I all r a ection prior to grouting and a final inspectiioonn..Si ned / ' Title: �'�" Date: za4,�& <br /> 9 <br /> (Draw Plot Plan on Revers Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I 4t <br /> Application Accepted By Date 1y <br /> Additional Comments: I <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT OrpER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE , 1, f <br /> LESS 'a / Q <br /> o V <br /> PPLUS RORATION iJ! 6 G4UV° <br /> PENALTY V}y�f IUlU <br /> OTHER (4 Ta <br /> ef~ O•rayd <br /> OTHER Yi <br /> Yr9^y lY <br /> 1 ` <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.Bax 2009 STOCKTON,CA 85201 .. <br />