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Applications Will Be Pr c ssed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -FOR OFFICE USE: ry APPLICATION r <br /> f V" <br /> Y For Non-Transferable Revocable Sus endabte <br /> / r / <br /> PUMP&WELL <br /> 4 ENVIRONMENTAL HEALTH PERMIT <br /> E (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 cam ance with San Joaquin County Ordinance No. 1862 and the rules and re uI tions of the Sa�{Joaquin Local Health District. <br /> Exact Site � G City/Town hCG I N <br /> Owner's Name `-- ©lU• 7 " Phone 1D SQ <br /> Address City �^ Oft��►'=OCth <br /> Contractor's Name License# iaBusiness Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION L <br /> WELL CHLORINATION 13 WELL ABANDONMENT E] OTHER E] PUMP INSTALLATION ®/ PUMP REPAIR❑ <br /> REPLACEMENT❑ W <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 /> II <br /> ❑INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> d DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> EOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> l IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICALr e Seal Insta led By; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 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 call f Grout Inspe ti n for to outing and a final inspection.. <br /> Signed X Title: Date: <br /> (Q w Plot Plan on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Aq/ Date -71A <br /> Additional Comments: <br /> Phase 11 Grout Inspection (,� a 111 Final spection <br /> Inspection By Date '"�r Inspection By r " Date -" /� i� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT X_PER SITE ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 <br /> BILLING REMITTANCE $ REMi7 <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT - <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -yr <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />