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Applications Will Be Pr_r cussed When Submitted Property Completed. Be Sure To Sign The Application. <br /> *FOR-OFFICE USE: �L APPLICATION J <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL 1_01 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY w . <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joa uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addressi <br /> City/TownG..- <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#f Business Phone <br /> Contractor's Address Emergency Phone ' <br /> Is Certificate of Workman's Compensatio Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOND PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> e <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 /> ❑ 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 /> ❑ DISPOSAL ❑ OTHER Other Information ��11 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: W, <br /> PUMP INSTALLATION: Contractor yI <br /> Type of Pump H.P. x.:+ <br /> PUMP REPLACEMENT: 19 State Work Done =s `n <br /> PUMP REPAIR: ElState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �j t <br /> Describe Material and Procedure <br /> 1 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 j <br /> is issued, I shall not employ any person in such manner as to became 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 a Grout Inspection prior to grouting and a final inspection. <br /> Signed XTitle: Date: -� <br /> Draw Plot Plan on Reverse Side) I <br /> F DEPARTMENT USE ONLY <br /> PHASEI <br /> i° <br /> Application Accepted By Date a ? 29 <br /> Additional Comments: <br /> Phase N 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 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY . <br /> OTHER <br /> r� <br /> OTHER �1 v <br /> Received by Date Receipt No. Permit No iH�AZELTON <br /> sate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. AVE.,P.O.Box 2009 STOCKTON,CA 45 1 <br />