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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. +. <br /> FOR OFFICE USE: / f / APPLICATION <br /> (For Non-Transferable, Revocable Suspendable) PUMP&WELL r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY,,;,,ti <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County O dinance No. 1862 a' the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> E rrt r + Phone <br /> Owner's Name j♦ <br /> Address 111 <br /> Contractor's Name a Licehse# Busiriess Phone ' <br /> Contractor's Address Emergency Phone f= ITlfs, s <br /> Is Certificate of Workman's Compensation Insurance on File th SJLHD? Yes No R <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL. ABANDONMENT-0 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑- Q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines - Pit Privy ` <br /> Sewage Disposal Field Cesspool/Seepage Pit — Other <br /> Property Line Private Domestic Well Public Domestic Weil <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 -a Surface Seal Instal d By: <br /> PUMP INSTALLATION: Contractor 1 0 <br /> }; .Type of Pump H.P. <br /> PUMP REPLACEMENT: s ❑ State Work Done ! i G <br /> PUMP REPAIR: ❑ State Work Done Q <br /> DESTRUCTION OF WELL: Well Diameter. ' p' 1 Approximate Depth C <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and thaCtlie 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 /> s Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 4 <br /> is issued, 1 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." w <br /> I wi call for a Grout Inspectio p `o grout g and a final inspection: <br /> ti � <br /> j Signed X w INe: Date: <br /> (Draw Plot Ian on Reverse Side) is <br /> ? Ao FOR DEPARTMENT USE ONLY <br /> PHASEI �7)_ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Ti Date Inspection 8 — Date <br /> Inspection By y <br /> F <br /> Fee Is Due: 11 ANEl PER UNIT 'ER SITE ❑ EACH' ` ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING._r y REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE IV IS <br /> LESS " Y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _4 <br /> OTHER : <br /> Received by 4 -y-r-Date Receipt No. Permit No. - Iss ante D to.=- Mailed - Delivered <, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />