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FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable,Suspendabi <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S <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 <br /> made in compliance with San Joaquin Cou y Ordi a 1862 and the rules and regulations of the San Joag�i�l LogI Health District. <br /> Exact Site Address City/Town .ie .&Y <br /> Owner's Name Phone <br /> Address <br /> City r <br /> Contractor's Name License Business Phone Zea <br /> Contractor's Address Emergency Pho e C <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No } <br /> TYPE OF WORK (CHECK): NEW WELI,,0 DEEPEN 13RECONDITIONDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ j , <br /> DISTANCE TO NEAREST: Septic Tank <br /> P Sewer Lines LSA Pit Privy <br /> Sewage Disposal Field 140 4- Cesspool/Seepage Pit Other <br /> I r <br /> Property LineF!h�Private Domestic WeIIL�QT 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 !r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION XROTARY T — <br /> r <br /> ❑ DISPOSAL ❑ Type of Grout <br /> OTHER Other Information <br /> ❑ GEOPHYSICALr` <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> 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-contractin ignature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued I shall mploy r ns subject to workman's compensation laws of California." <br /> I call for aArou gdpect' !or to grouting and a final Inspection. <br /> Signed X Title: Date: T, e, i <br /> (Draw Plot Plan on Reverse 0e) i <br /> 1 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By A* Date 714V <br /> O <br /> Additional Comments: or <br /> Ja4selrout spection Phase III Final Inspection <br /> Inspection ByDate MiInspection By l's Date <br /> Fee Is Due: [EllAN ❑ PERUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> [I DATE DATE REMITTED r, AMOUNT <br /> FEE `93 <br /> LESS Y <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 PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />