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' Applical Will Be Processed When Submitted Properly Completed:Bill To Sign The Application. , <br /> I FOR OFFICE USE: APPLICATION / <br /> (For Non-Transierable, Revocable, Suspendable) v <br /> " ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> t <br /> (COMPLETE IN TRIPLICATE) WATER gUALITY v' <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstruct and/or install the work herein described.This application is <br /> made in cpliance with San Joaquin Count Ord nce No. 1852 and the rules an regulations of the San Aaguin LocN Health District. ' <br /> Exact Site Address — i /Town <br /> Owner'sjj%amp .> Phone <br /> Address City o� <br /> Contractor's Name . License# c,2g00&5 Business Phone <br /> Contractor's Address ergency Phone 153e6---a27/ _ <br /> Is Certificate of Workman's CompensationIns rance on File With SJLHD. Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �/� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El v <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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ <br /> I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing P,0� l <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing GCJlL2�� _ <br /> ❑ IRRIGATION GRAVEL'PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout s, <br /> ❑ DISPOSAL ❑ OTHER Other Information 1..� --d/ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL. Well Diameter A Approximate Depth �n <br /> Describe Material and Procedure v I <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 sl nature certifies h <br /> g e est a following."I certify that in the performance of the work for which this permit r <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 11 for a Grout Inspection p . to grouting and a final inspection. <br /> Signed X Title: Date: A?/ <br /> (Draw Plot Plan on Rev si3 Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �( Q <br /> Application Accepted By 02 Date' <br /> U <br /> Additional Comments: <br /> Pha it 13rout Inspection/; Phase III FmalWnspectlon t <br /> Inspection By ' Date j Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED , <br /> AMOUNT <br /> e <br /> FEE $ ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER CC� <br /> Received by t Date Receipt No. Permit No _ - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-'Box 2009 STOCKTON,CA 95201,- <br />