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ApplicationsWill Be Processed When Submitted Prop <br /> FOR OFFICE USE; erly Completed. BeSureTo-Sign The Application. <br /> 6 <br /> ` APPLICATION <br /> (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 District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin Cnty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> City/Town <br /> Owner's Name <br /> Address F) i... Phone -� �- � <br /> Contractor's Name 7z.JCity <br /> izesi; License# / Business Phones} �r <br /> Contractor's Address "r <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NO <br /> 11 -- <br /> WELL CHLORINATION WELL ABANDONMENT 11 OTHER 1:1 PUMP INSTALLATION dlpUMP REPAIR I] <br /> REPLACEMENT❑" <br /> DISTANCE TO NEAREST: Septic Tank f <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage"Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> 2 LEI IN� ❑5TRIAL TYPE OF WELL <br /> �� CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> 11 El Dia. of Well Casing <br /> ❑ IRRIGATION El DRIVEN Gauge of Casing <br /> C1 GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION <br /> ❑ DISPOSAL RType of Grout <br /> ❑ GEOPHYSICAL OTHER <br /> R Other Information <br /> PUMP INSTALLATION: �,Syrface Seal Installed By; <br /> Contractor Z, <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 114 <br /> DESTRUCTION OF WELL: Well Diameter (^ <br /> Describe Material and Procedure Approximate Depth ` <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:"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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I iI f r"a G ut nspeciion prior to grouting and a final inspection. <br /> Signed <br /> Title: _ = Date: ` <br /> (Draw Plot Plan on Reverse Side) <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase 11 Grout Inspection <br /> Inspection By. ha&I Final Inspection <br /> I Date Inspection By <br /> � Date <br /> Fee IS Due: ❑ ANNUALLY PER UNI7PER SITE � - <br /> ❑ EACH ❑ Jan nary 1 &Received By January 31 <br /> ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS } <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> w <br /> Received by Date Receipt No.- p <br /> ermit No. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENYfAONMENTAI HEALTH PERMITISERVICES Delivered <br /> .��_ 1601 E.HA2ELTON AVE.,P.O.Boa 2009 STOCKTON-r_a oa�n, <br />