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FOR OFFICE USE. APPLICATION <br /> Qor Non-Transferable,Revocabie, Suspendable] PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebyrnadetothe San Joaquin Local Health Distric6ora'ipeimit tobonstruct and/or installthb work r i dfr <br /> bOppl ationis <br /> made in compliance withSan Joaquin CountyO financeNo. 1862andthe rulesand regulations oftheSan Jo ui� ea'Iitit <br /> Exact Site Address City/Town <br /> Owner's Ilam . . Phone_ !;� <br /> Address City <br /> Contractor's Name = License#- <br /> Business Phone. <br /> Contractor's Address 41';-•' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYP -OF-WORK (CHECK): NEW WELL El DEEPEN-❑ '-RECONDITION❑.-:.. DESTRUCTION,❑� ~ <br /> W L CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 .PUMP INSTALLATION � PUMP REPAIR❑ <br /> EPLACEMENT❑ L <br /> STANCE 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 /> JNTENDED USE TYPE OF WELLRR' " <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 S" <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL;._ Surface Seal Installed icy:. E,, <br /> S. <br /> PUMP INSTALLATION: Contractor <br /> 4 " <br /> Type of Pump _ H.P. <br /> ',PUMP REPLACEMENT ; ❑ State Work pone <br /> PUMP REPAIR- ❑ State Work Done <br /> DESTRUCTION OF WLLi (Nell Diameter . <br /> pproximate 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 /> Home owner or licensed agent's signature certifies the followiny;,:a.certify thlt—iA the performance of the work for which'th i permit ? <br /> i9sued;itt"s i'a not ertiploy=any perso-n-m"such m'an er as to_becomesubject to workman's compensation laws of GaliI ornia." <br /> Contractor's:hiring or sub-contracting signatufe certif1s the following:"I certify that in the performance of the work for which this <br /> Perm it is issued, I shall employ persons subject to.woAman's-compensation laws of California." <br /> -- I will call or a Gro4W pection prior to grouting and a final inspection. b <br /> Signed 1 T�lile: 1y� -- Date. <br /> (Draw Pot Plan=on Reverse Side) <br /> e , <br /> FOR DEPA IMENT USE ONLY <br /> PHASE E <br /> Application Accepted By'—,- Date <br /> Additional Comments: ;+ y <br /> ` Phase 110rout Inspection,.--, -PhasA�alction <br /> Inspection By .Date . `°`�} Ins ection By ate <br /> P <br /> Fee Is Due: ❑ ANNUALLY ❑-PER UNIT ❑ PER SITE ❑EA H- t b•January 1 &Received By January 31 ❑ July 1 &Received By',July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION AMOUNT DUE, CHECKID <br /> DATE DATC'-'° REMITTED AMOUNT <br /> FEE' <br /> LESS <br /> PRORATION 5 <br /> PLUS <br /> -- l <br /> PENALTY - <br /> OTHER . ... ' <br /> i <br /> 1 OTHER - -•.r: - .. <br /> � z <br /> Re ,,l by Date Receipt No. P rmit No. - ,. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />