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Applications Will Be Processed When Submitted Properly Completed.,Be Sure To Sign TheAp li n. <br /> FOR OFFICE USE: APPLICATION <br /> --^� (For Non-Transferable,Revocable;Suspendable) PUMP& ELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) . WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/ install the work..herein described.This application is <br /> made in compliance with S,ann,Joaqum.Count r mance No. 1 2 and the Kgrid regulations of the San Joa" u' ocal Health District. <br /> Exact Site Address_�__�iy'F� /I�! City/Town r <br /> Owner's Name is oPhone <br /> Address ejl�' rt. CityJa a <br /> Contractor's Name 05 License# 7'"" - Business Phone . G to-��Gz <br /> Contractor's Address dEmergency-Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ ". RECONDITION❑- '�'DESTRUCTIO ❑` - —S)WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 1 <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT ❑ State Work Done Q <br /> PUMP REPAIR,- ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: "� �`��d <br /> (Draw Plat Plan on Reverse Side) <br /> t <br /> FOR DEPARTM NT USE ONLY <br /> PHASE I ��f� . <br /> Application Accepted By Date <br /> Additional Comments: <br /> —Phase IJ Grout Inspection / �_P)p�sy�,�l F Iilsp'ection� <br /> Inspection By ��_ Dat �J( Inspection By�f�vD a Date 6 �� <br /> Fee Is'DUe:'❑ ANNUALLY '❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 ❑ Juty 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> 7�7 107 <br /> LESS ' <br /> PRORATION t . <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER .. --Y+,r.• - .. a �. ,. . ti <br /> Received 6y ate Receipt No, Perrnrt No. t 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 />