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r ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application..— <br /> jFOROFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> c <br /> made in compliance with San Joaquin <br /> Exact Site Address County Ordinance No. 1862 and the rules and regulations of the San Joaqui Lo I Health District. <br /> County <br /> +� <br /> City/Town .✓ d <br /> i Owner's Name r <br /> Ad d res5 <br /> Phone <br /> ,�u� City <br /> Contractor's Name - License 8 <br /> 00, <br /> Business Phone G <br /> Gantractor's Addre Emergency Phone +G <br /> Is Certificate of Workman's Compensation Insura on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL�p EPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL AB NDO[NyMENT V OTHER ❑ r <br /> REPLACEMENT❑ olor ill PUMP INSTALLATION PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank _ <br /> p S Sewer Lines Pit Privy <br /> Sewage Disposal Field ,e grerCesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well Other <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ee- <br /> I ,�- ❑ CABLE TOOL Dia. of Well Excavation <br /> k =DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> t ❑ CATHODIC PROTECTION Ri-P—OTqRY <br /> C1 DISPOSAL DISPOSAL Type of Grout Y <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .- <br /> PUMP INSTALLATION: Contractor <br /> Ile F <br /> Type of Pump J 1 <br /> PUMP REPLACEMENT: ❑ <br /> State Work Done H,P. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ' <br /> ) <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure r. <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 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 c I for a Grout Inspection prior to grouti and a final inspection. <br /> Signed X �yfT Title: <br /> (t7 raw Plot Plan on ReverseSide) Date: �B <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Date <br /> Phase II Grout inspection <br /> Inspection By Date `- �i Phase Final Inspection <br /> Inspection By� _ Date L Cf1— <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH - <br /> ❑ January 1 &Received By January 31 _ ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE S O a AMOUNT <br /> LESS it <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rntba-- 6s l spa <br /> Received by, L)at4 Receipt No Permit No, <br /> Issuance Date :Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> . - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br />