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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOI.OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin C unt rdinance No. 1862 and the rules and regulations of the SanA aquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's toiT, t Phone <br /> Address _ City <br /> Contractor's Name icense# 3 Bu ess Phone <br /> Contractor's Address 1 e geTi Phone I <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 8'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Q <br /> REPLACEMENT❑ f 7' / S <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool%See page Pit " Other N 4. <br /> Property Line_J _ Private Domestic Well Public Domestic Well �I <br /> INTENDED USE TY OF WELL <br /> LJINPUSTRIAL E TOOL Dia. of Well Excavation <br /> ®/DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION E] ROTARY Type of Grout _ � irl/ ., <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: I <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done C <br /> PUMP REPAIR: ❑ State Work Done r <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:"1 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." 5 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ll for a Grout Insp ct' n prior to grputing and a final inspe on. <br /> Signed X ` Title: 1 - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR Q ARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> a Grout'5 <br /> ection Final I ection <br /> Inspection Bye r1 Dake �� 0 inspection By � - Date <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT PER SITE ElEACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT t <br /> t: <br /> FEE <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER i <br /> OTHER <br /> s - <br /> Received .� � ,. - ti Date, Receipt No. Permit No. Issuance Date Mailed Delivered i <br /> =' E.H <br /> APPL'ICANT��. �RET.URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160 iEA2 LTON pVEy�rw.O.Box 2 5 TON,CA 95201 . <br /> ' ��,. �s/ <br />