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Applications Will Be Processed When Submitted Properlycomplerea. on auto IV �a•• ^rr•• <br /> FOR-0 - ICE USE: APPLICATION / <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL 4 ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> F (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work.herein described.This application Is <br /> made in compliance with San Joaquin Count Ordinance l Health District. <br /> �No. 1862 and the rules and regulations of the' Joaquin Loca <br /> Esc, / _� F f City/Town • <br /> Exact Site Address 2_ P G�j <br /> Phone �- ` 0 1 <br /> Owner's Name City <br /> z 1 <br /> Address � r <br /> .�..- License�••� 7C Business Phone <br /> Contractor's Name <br /> Contractor's Address i Emergency Phone N <br /> 1 Is Certificate of Workman's Compensation Insurance on File h SJLHD? Yes <br /> No � <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> I REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I ❑ lUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal W <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I. ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> U <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> I PUMP REPAIR: ❑ State Work Done t, <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> � <br /> l• 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 /> 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, l 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 I a Grout,l pection prior to grouting and a final inspection. t <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> Date <br /> Application Accepted By - <br /> Additional Comments: <br /> Phase 11 Grout Inspection �11pectioDate Inspection SyDate <br /> d By <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑-PER UNIT F-1PERSITE. ❑ EACH ❑ January 1 &Received Ry January 31 ❑ July i &Receive <br /> REMITuIy 31 <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I. OTHER <br /> OTHER <br /> 83 .2 <br /> Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. Issuance <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />