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^rr..4 lung nwererrocessea vvnen auomrnea rroperry%,ompiewo.oe aure IQ algn r ne rippllcauon. <br /> [IOR OFFICE USE: APPLICATION <br /> ' (For Non-Transferable, Revocable, Suspendab <br /> 1 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora Permitto construct and/or install the work rein described.This application is <br /> male in compliance with San aquin ounty Ordin ce No. 18rii2zD_d the rule nd re #i sof the San pc k Ict. <br /> Exict Site Address .� <br /> Pity/Town <br /> Owner's Name <br /> Ad4ress Phone <br /> t <br /> Contractor's !Name City <br /> �icense usiness Phone <br /> Contractor's Address e <br /> Emergency Phone / <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL 91 DEEPEN ❑ RECONDITION❑ DESTRUCT ON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION *PUMP REPAIR❑ t <br /> REPLACEMENT❑ <br /> Q> <br /> DISTANCE TO NEAREST: Septic Tank //;L[1 Sewer LinesL <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage PitOther <br /> Property Line-/4140-Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND `TRIAL ❑ CABLE TOOL �r <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well CasiExcang <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Dia. of Well Casing , <br /> El IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION &IiOTARY <br /> 11bISPOSAL Type of Grout <br /> ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL ace Seal Instal By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , H,P. <br /> j <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter { <br /> Approximate Depth i <br /> Describe Material and Procedure <br /> 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 /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call or a Grout Inspection prior tc�irutl g and a final inspection. �! <br /> Signed X Title: <br /> Date: C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> u�^O <br /> 4UZZT <br /> pection r P e III Final Inspection ) <br /> Inspection By Date � 1 Inspection By Date j <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31' <br /> BASE - EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date27) <br /> Receipt No. Permit No. Issluande Date Mailed <br /> APPLICANT- RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - Delivered <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />