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pplicatfonsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EFORItFFEJ APPLICATION f <br /> (For Non-Transferable, Revocable, Suspendable) <br />' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL III <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY e <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This applic�ion is <br /> made in compliance with San Joaquin Cc ' Ordinance No. 186 and the rules and regulations of the San oaqu' Local Health District. <br /> Exact Site Address City/Townr <br /> Owner's Name s.,y <br /> Address � � Phone *.[. <br /> ' <br /> Contractor's Name J CityLicense# Busine Phone' - 3.3 <br /> Contractor's Address 0 mergency Phone � � 3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN E] RECONDITION <br /> RECONDITION❑ DESTRUCTION❑ <br />! WELL CHLORINATION ❑. WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ lO <br /> DISTANCE TO NEAREST: - Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well l <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ 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 /> C1 DISPOSAL Type <br /> Other Information <br /> 13 GEOPHYSICAL r... Surface peal Installed 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 <br /> 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 forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Grout Inspection p ' r to grouting and a final inspection. <br /> Signed X (`�1 Title: <br /> 1ate: <br /> (Draw Plot Plan on everse Side) <br /> i <br /> PHASE FOR DEPARTMENT USE ONLY <br /> ' <br /> Application Accepted By e,rr Y <br /> Additional Comments: <br /> Date 2Z4c/ <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date � � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July} &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE g REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1/ 7, AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b y t <br /> Received 1)Y ate -7 <br /> Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - - 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCI(TON.CA 95201 <br />