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Applications Will Be Processed When Submitted Properly � <br /> FOR OFFICE USE: APPLICATION / <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> x, /ll��1D 9 WATER QUALITY <br /> (COMPLETE IN TRIPLICATE1ork <br /> Application sherebymadetothe San Joaquin Local Health District for ap r he rules and mit to ectaationsoftalIthethp nJoaquinlLocalcHea�hTDisthis iPp �atior ,5 <br /> made in coupliance with San Joaquin County Qrdinance No.1862 and t <br /> Exact Site Address <br /> Phone J <br /> Owner's Name City <br /> Address d ��ng <br /> Li ense# 2 Business Phone <br /> i` Contractor's Name Emergency Phoneme z �1 <br /> Contractor's Address No <br /> DEEPEN <br /> rr � <br /> Is Certificate of Workman's Compensation In urancEPEN Q ith 5R C11ONDITION DESTRUCTION❑ lJ� <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION 11WELL ABANDONMENT IJOTHER 13PUMP INSTALLATION C] PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Privy �J <br /> DISTANCE TO NEAREST: Septic Tank /02 Sever Lines ether <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Weil <br /> INTENDED USE <br /> TYPE OF WELL I J' <br /> 13 INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation— <br /> ❑ DRILLED Dia. of Well Casing f <br /> X DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN ROTARY Depth of Grout Seal Type of Grout <br /> 11 IRRIGATION GRAVEL PACK <br /> ❑ CATHODIC PROTECTION Other Information <br /> 11 DISPOSAL <br /> 11 OTHER <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> t Describe Material and Procedure <br /> 4 lication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this app <br /> Joaquin Local Health District. <br /> ordinances, state laws, and rules and regul.Ations of the San <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 /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k I will tall for a Grvu nsp tion prior to grouti g and a final inspection. ry <br /> Title: Date: <br /> Signed X <br /> e (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase til Final Inspection <br /> p e I rout),nspection � Date <br /> Inspection By Date <br /> • r Inspection By <br /> January 31 [J July 1 &Received By <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE [_1 EACH ' ❑ January 1 &ReceivedReceivedMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Wnc, <br /> Receipt No. Permit No. Mailed <br /> Received by Date Delivered <br /> ., TAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMEN <br />