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A II tions Will Be ProcesswW ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: JANa� tq� APPLICATION n� <br /> •G %;or Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> SAT'4" J0,AQt111V L ftLRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATEPEALTH DISI ICT WATER QUALITY <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 wi uinComirty Okdinance No. 1862 nd a rules and regulations of the S quin Locale,a4ty�ti <br /> Exact Site Address '��r City/Town <br /> Owner's Nam QUA. Phone �� 7 <br /> Address ! 1e'1'_1City <br /> Contractor's Name �'� License# Business Phone A <br /> Contractor's Address J S Emergency Phone ) <br /> Is Certificate of Workman's Compensation Insurance 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❑ <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 /> ❑XVDUSTRIAL ❑ 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 _ 4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / P <br /> face Seal Installed By: <br /> PUMP INSTALLATION:V Contractor 0 <br /> Type of Pump H P. <br /> PUMPREPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> 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 /> Home owner 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 ng or sub-con ng signature certifies the following:" rtify that in the performance of the work forwhich this <br /> per d, I hall em oy per ons subject to workman's comp ation laws of California." <br /> I ill ut In n r t ou Ing and a final ins do <br /> Signed X Ti Date: / J <br /> (Draw Piot Pla on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection a III Fin I Inspection <br /> Inspection By— Date Inspection By Date 2— <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 8,Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> em <br /> FEE ��� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Daite Mailed Delivered j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 TJ <br />