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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> -tFor Non Transferable, Revocable, Suspendablt. M, PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application ishere a oaq Lo all ealth District fora permitto constructand/or install thework herein described.This application is <br /> mej�1RXIIJ <br /> 1�1 i n o um Co r Inaitce and the ruleand regulations of the Sanaquin Local Health District. <br /> E ess `' City/Town T.lr'�"`—Y7� <br /> Owner's �� '�fto Phone� 3 <br /> Address City <br /> Contractor's Name . License# a usiness Phone r <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? . Yes—- Ne-- No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br />'I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUIVIR—REPAI$ <br />' REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit the <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 /> 0-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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> �4 <br /> PUMP REPLACEMENT: ❑ State Work Done .., .. \ <br /> PUMP REPAIR: XStete Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material and Procedure kv <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 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 /> 1 will call for a Grout Inspection prior to grouting and a final insp on. - <br /> Signed X Title:. Dale: 3 r� <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASEI - <br /> i <br /> Application Accepted By Date <br /> Additional Comments, <br /> Phase 11 Grout Inspection Pha Ill at Inspection <br /> --,Inspection By -Date Inspection-By Date <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ January'1&Received By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bar 2009 STOCKTON.CA 95201 <br />