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ir Applications Will Be Processed When Submitted Properly Completed. BepWI la�sign inewppncdiwr+. <br /> rFOR:OFFICE USE: APPLICATION $Ep 25 �9g <br /> (For Non-Transferable, Revocable, Suspendab a PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN �ppQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTH DISTRICT <br /> 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 e <br /> made in compliance with n/ aq n Cou rdinanc 18 2 a e rules and regulations of the San J�C�quinLoc��lAlistrict. <br /> Exact Site Address " r ® � City/Town �� <br /> �,eRJ �r/ . Z �� Phone <br /> Address <br /> Owner's Na s �d� <br /> Address City <br /> Contractor's Name Q✓ JP U License Business Pho e <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 Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> a <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 /> PUMP REPAIR: M State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> m <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 per it <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I <br /> i Contractor's hiring or sub ntracting signature certifies the following:"I certify that in the performance of the work for which t Is <br /> permit i ed, I shall mplo persons subject to workman's compens tion laws of California." <br /> W, rout Ins cti prior to routing and a final ins �7_ <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on everse Side) <br /> f FO DEPART ENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase Ili F' al Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ T-1 DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � � <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 OTHER <br /> FIIi OTHER <br /> 1 a 9 17 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered. <br /> APPLICANT—RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />