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Applications Will Be Processed When Submitted Properly Completed.Be sure 1obign IneFlppuaaua»r. <br /> r <br /> FOA OFFICE USE: J APPLICATION <br /> /&q�id� (For Bion-�-'ra sferable, Revocable,Suspendable) PUMP&WELL <br /> [ ENVIRONMENTAL. HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is N TRI LICATmade the San Joaquin Local HealthDistrictforapermittoconstructand/oi•installthework herein described.This application is <br /> made in compliance with San Joaquin County dinanc No.1862 and the rules and regulations of the San Joaquin l�c�lgea� District. <br /> Exact Site Address rK City/Town �� <br /> r <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name S <br /> License#I 7y� Business Phone <br /> Contractor's Address a� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK)- NEW <br /> WW LL <br /> DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINpA�►TION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT)u <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 /> © INDUSTRIAL <br /> ElCABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing yl. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information x <br /> Surface <br /> al Installed B a <br /> j <br /> 13 GEOPHYSICAL a Y <br /> PUMP INSTALLATION: Contractor " H.P. <br /> r Type of Pump <br /> .— <br /> PUMP REPLACEMENT: 0 State Work Dorie-T <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. i <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 for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wi call for a Grout Inspection 'or g utin an a final inspection. <br /> Signed <br /> le: — 39 rate: <br /> (Draw Plot an n Reverse Side) <br /> FOR DEP TMENT USE ONLY <br /> PHASEI <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II G out Inspection P ase 111 Final inspection, t�D <br /> Inspection By <br /> Date Inspection By Date <br /> 0/1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> �. FEE Sr � <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: AMITlSERYICESUd t 01 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> Received by ENVIRONMENTAL HELTH.PER —mew-0 <br />