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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY oQ <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is O <br /> made in compliance with San Joaquin County Ordnance o. 18 2 and the rules a d regulations of the San Joaquin Local Health District. f <br /> Exact Site Address <br /> City/Town <br /> Owner's Name Y _® <br /> Address <br /> ., Phone - <br /> City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address ` Emergency Ph ne ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT ❑ OTH� PUMP INSTALLATION ❑ PUMP REPAIR 13 " { <br /> REPLACEMENT "f <br /> DISTANCE TO NEARE T: eptic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other a <br /> Property Line Private Domestic Well Public Domestic Well <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P -44 <br /> PUMP REPLACEMENT: 11State Work bane M <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." f <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 Inspection prior to grousing and a final in;everse <br /> e ' n, <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Side) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 1 I Fin spection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ - REMIT <br /> DATE DATE REWTTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> Received by Date Receipt N. Permit No. Issuance Date <br /> Mailed D ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />