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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION A <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)`S fir L, C ATER QUALITY <br /> r; <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or.install the work herein described.This application is <br /> made in compliance with San Jo quip Co my rdinance No. 186 nd the" r les and r gu ations.of the Sanaquin Loca Health District. <br /> Exact Site Address City/Town g0 <br /> Owner's Name ,, Phone <br /> Address City <br /> Contractor's Name License# �'C/d Business Phone ""` 51ej <br /> Contractor's Address U .� Emergency Phon —00,4501 F <br /> Is Certificate of Workman's Compensation Ins rance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): IQW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © -PUMP INSTALLATION L] PUMP REPA15a {� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines s w Pit Privy-. }[ <br /> Sewage Disposal Field Cesspool/Seepage Pit = Other ' <br /> '`t?roperty,Line Private Domestic Well Public"bomestic Well <br /> 'INTENDED USE x� TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE" ❑ DRILLED Dia- of.Well Casing <br /> DOMESTIC/PUBLIC �`¢ E] DRIVEN Gauge of Casing -- ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �L <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '' <br /> r❑ 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 of <br /> PUMP REPAIR: <br /> 19 State Work Done <br /> DESTRUCTJON OF WELL: Well Diameter Approximate Depth <br /> I 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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of:California." ' <br /> I will call for a Grout 1 spection prior to grouting and a final inspeciinn. .- <br /> ''' yam/ <br /> Signed X Title:.. - Date: i <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT-USE ONLY 1 <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: e <br /> Phase It Grout Inspection Phas III F' al Insp ction <br /> Inspection By•- Date Inspection By Dale /a <br /> . i <br /> Fee Is Due: ❑ ANNUALLY " ❑ PER UNIT ❑-PER-SITE ❑ EACH ❑ January I &Received By January 31 ❑ July t &Received By July 31 f <br /> BILLING REMITTANCE $ t REMIT f <br /> BASE - EXPLANATIONBILLING <br /> DATE EMITTED a AMOUNT DUE CHECKED - <br /> AMOUNT i <br /> FEE A 4's d <br /> LESS-- t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - - - <br /> OTHER ` •� -7 <br /> Ao <br /> Received by -Date Receipt No. Permit No. Issu ce Dato Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES f `1601 E.HAZELTON AVE.,P.O.Boll 20119 STOCKTON,CA 95201 <br />