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FOR OFFICE USE; APPLICATION <br /> For Non-Transferable, Revocable, Suspendable <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (CO,'dIPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is t <br /> made in compliance with San Juaqui unty Ordinance No. 1862 and the rules and regulations of the S JoagJ in Local Health District. <br /> Exact Site Address _ City/Town / /1 <br /> Owner's Name" Phone <br /> Address ` �— ^ City <br /> Contractor's Name License# Business oh ne /'�froo "(,, 1?/ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ElRECONDITION DESTRUCTION❑ U <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ IS, <br /> REPLACEMENT <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 <br /> ❑ GEOPHYSICAL urf ace eaI stalled By: <br /> PUMP INSTALLATION: Contractor o ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ state Work Done ?<->- <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter 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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Ins ection prior to grouting and a final inspectiop. <br /> Signed X ` �- Title: 0 ( _ Date: G1 - <br /> (Draw Plot Plan on R4V6rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �J - Date-�r�`��Y7- <br /> Additional Comments: <br /> Phase II Grout Inspection P a III Fi al Inspection <br /> Inspection By Date— Inspection B Dat���� __ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCEf $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> c AMOUNT <br /> FEE �J � �1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Diie Receipt No. ermit No. Is uanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 9520 <br />