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ppncanonsWilltaeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> ---------- <br /> EFOR APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> f <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described,This application is <br /> made in compliance with San Joaquin C <br /> Exact Site Address ounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> . f <br /> City/Town <br /> I Owner's Name <br /> Address Phone <br /> Contractor's Name City <br /> Contractor's Address G, License# 2/ Business Phone 7 <br /> 1;;~ <br /> Is Certificate of Workman's CompensG 2 Emergency Phone 4978 <br /> ation Insurance on File With SJLHD? Yeses <br /> No <br /> 9 TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION LJ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONR PUMP <br /> REPLACEMENT REPAIR❑ <br /> ❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic WellPblic Domestic Well Other <br /> INTENDED USE TYPE OF WELL u <br /> ❑ INDUSTRIAL <br /> 13 CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE _ <br /> 11DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION � � ❑ GRAVEL PACK <br /> 11CATHODIC PROTECTION 13Depth of Grout Seal <br /> 13 DISPOSAL ROTARY Type of Grout <br /> ❑ OTHER <br /> ❑ GEOPHYSICAL � Other Information <br /> i PUMP INSTALLATION: .._ Surface Seal Installed By; <br /> Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> P State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 orsub-contracting signature certifies the following:1 certify that in the performance of the work for which this I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> it <br /> I will call for a Grout In final prior to grouting and a-final inspectio - - <br /> Signed X <br /> Title: Date: <br /> {Draw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE ONLY ? <br /> PHASE <br /> Application Accepted By r <br /> Additional Comments: Date J 7/A0 <br /> Phase 11 Grout Inspection <br /> Inspection By Pha nal inspection <br /> Date Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY � � ; <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH j <br /> 0 January 1 &Received By January 31 07 <br /> ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT , <br /> DATE DATE MITTED AMOUNT DUE CHECKED <br /> FEE 4A C. AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER [` <br /> J <br /> OTHER - <br /> fr`` -•[sem) R <br /> Received by -Date Receipt No. <br /> Permit No. Issu nce Date Marled <br /> UZAred <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box-2009 S CKTON,CA 95201 <br />