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.,, Applications Will Be' Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> l7FICE USE: 1 APPLICATION' <br /> C �t } <br /> O /tt? JJ�l'� (For Non-Transferable,Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfor:a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin qounty Ordinance No. 1862 and the rules and re Mations of the San Joaquin Local Health District. <br /> Exact Site Address 1 � �' City/Town <br /> Owner's Name Phone <br /> Address f - rt tl . City <br /> Contractor's Name <br /> License# I Business Phone_ <br /> Contractor's Address ~' e� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ) <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ -4 <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 /> i INTENDED USE TYPE OF WELL <br /> f 1�I3,� INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> la DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> 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 ze d6 A H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP fiiler 111 State Work Done "ire' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Ap oximate Depth <br /> y" Describe Material and-Procedure t <br /> t 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 performarice.of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> fi <br /> I [II call for a Grout Inspectio rio to rdttt' g and a final inspection. _ <br /> Signed 42 <br /> Me: Date: [- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE l <br /> I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection eJ Inal Inspection <br /> Inspection By I 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 $ <br /> DATE DATE REMITTE AMOUNT DUE CHECKED it <br /> ! AMOUNT <br /> 44�S 1 <br /> FEE Ilk j <br /> F <br /> LESS <br /> PRORATION - <br /> • 4 <br /> PLUS <br /> PENALTY <br /> OTHER - f i <br /> i <br /> OTHER <br /> z B <br /> Received by Date Heceipt No. Permit No. Isbuance pate Mailed Delivered - <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />