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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT -3-11 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY r <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 /> .>�... <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin.Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address O City _ <br /> Contractor's Name License#� Business Phone'-= <br /> Contractor's Address � '� - goLc � - Emergency Phone ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONO'" - DESTRUCTIO,N,❑ -- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER El PUMP INSTALLATION � PUMP REPAIR❑ �J <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other S <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> Cl INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �OMESTIC/PRIVATE EI 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' ►O, <br /> ITYPe of Pump., .d -t`r— H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 Sari 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 /> S.i for a Grout prior to grouting and a final inspection. <br /> Signed __ Title: rel Date: — <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By s Date <br /> Additional Comments: <br /> O <br /> Phase II Grout Inspection h inal Inspection <br /> Inspection By Date Inspection By Date <br /> i, <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH' ❑ Janvary 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 <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -..Date-- " Receipt No. Permit No. Issuance Date- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />