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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. .J <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r' <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br />{ Application is hereby rnadeto the San Joaquin Local Health District for a permit to construct and/or instal I the work herein described.This application is <br /> made in compliance wo San Jo in C unty Ordinance No. 1862 and the rules and regulations of the San J9AqUin Loc eafth District. <br /> Exact Site Address Z' _� City/Town 2 4� <br /> Owner's Name Phone Q <br /> Address City <br /> ' Contractor's Name License !� "Busin ss Phone 6 Z <br /> Contractor's Address r Emergency Phone .Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> z1_ <br /> TYPE OF WORK (CHECK): NEW WELL -DEEPEN ❑ 'RECONDITION❑ DESTRUCTIONpd- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> I REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer-Lines Pit Privy <br /> r Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation ` <br /> P.DOMESTIC/PRIVATE- ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ` <br /> El IRRIGATION E] -GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r/ b <br /> ❑ DISPOSAL ❑ OTHER l Other Information <br /> ❑ GEOPHYSICAL S4rface Seal Installed By:�9Ltz <br /> PUMP INSTALLATION: Contractor h <br /> Type of Pump H.P. } <br /> PUMP REPLACEMENT: ' ❑ State Ulork Dbne <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 /> l ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> " <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 thew ork for which this <br /> permit is issued, I shall employ persons'subject to workman's compensation laws of California." <br /> I will call forte-E`xro�ut Inspection prior.o grouting and a final inspection. G� <br /> l Signed X ✓ Title: �j y Date: r <br /> t (Draw Plot-Plan on Reverse Side) <br /> S� FOR DEPARTMENT USE ONLY <br /> PHASE I IJtJ�a�1� pate , 1s-Sr <br /> Application Accepted By <br /> Additional Comments: <br /> hase II Grout/inspection ase III Final Inspection <br /> Inspection ByA7 Date yc?f`v Inspection By - Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 &Received By January.31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> t BILLING REMITTANCE_ $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE" 'REMITTED <br /> Q AMOUNT <br /> FEE <br /> LESS p <br /> PRORATION ----- <br /> PLUS <br /> -PLUS <br /> _ PENALTY <br /> OTHER <br /> LOTHER <br /> eceived by ate Receipt No. Permit No Issuance Date Mailed Delivered f" <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTONAYE.,P.O.aox 2009 STOCKTON,CA 95201 <br /> - <br />