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-Applications pli <br /> catkons Will Be Processed When Submitterd Properly Completed. BSureTo <br /> FOR OFFICE USE,` APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> r` ENVIRONMENTAL HEALTH PERMIT J <br /> (COMPLETE; N"TRIPLICATE) <br /> WATER QUALITY / <br /> 7 Application is hereby made to the San Joaquin Local Health District fora permitto construct.and/or install thework herein described-This application is <br /> made in compliance with San Joa ui County Ordinance No. 1862 and the rules and re ul sofa oaL al He Ith District- <br /> qq 'r <br /> n410GcJ�2arf�uceJ_ W � _0 �f- 1y own <br /> Exact Site Address ,2Q t � <br /> Phone 6 09 <br /> Owner's Name <br /> Address City �`� <br /> Contractor's Name License# 9Z Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> — - <br /> r <br /> TYPE'OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank 7o Sewer Lines Pit Privy /I <br /> t Sewage Disposal Feld Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> I TYPE OF WELL <br /> INTENDED USE Ife <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> l{ ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 4 ❑ CATHODIC PROTECTION 3�ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> K <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: f ❑ State Work Done <br /> DESTRUCTION OF WELL:k _ .. Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> # 1 hereby certify that p p <br /> l 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 orsub-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 c II for a Grout Inspectio rior to grouting and a final inspection. <br /> Signed X <br /> Title: Date: 7 �l <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Q —� <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phas 11 out Inspection Phase 111 Final Inspection <br /> Inspection By Date Y Inspecti n By Date <br /> or <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER S E C7 EACH ❑ , nuary 1 Received By January 31 C1 July 5 &ReceiveREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> f LESS <br /> PRORATION <br /> PLUS <br /> t PENALTY <br /> OTHER <br /> OTHER <br /> 4 (o <br /> q__�issuance Date Mailed <br /> Received pate Receipt No Permit No. <br /> d bDelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CR 95201 <br />