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L Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> FORtP_FFICF,,USE: APPLICATION <br /> r (For fJon-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 16 <br /> made in compliance with n Joa uin Count Ordi ce 18 nd r s and regulations of the San qui Local Health District. <br /> - Exact Site Address � ! ✓r rr/ City/Town <br /> Owner's Name Phone <br /> i Address City 3 j <br /> Contractor's Name (cense Business Phone elk / Q <br /> Contractor's Address 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❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank 1040 "04- Sewer Lines /oa T` Pit Privy <br /> Sewage Disposal Field Cess poo[/Seepage Pit ' <br /> �Q—� Other ~ <br /> i Property Lined Private Domestic Well_�t-Public Domestic Well W <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ®'1SOMESTIC/PRIVATE -URILLED Dia. of Well Casing r�?L <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t. ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION &I�OTARY Type of Grout �^ <br /> k © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install d By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump <br /> PUMP REPLACEMENT: ❑ 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 /> I <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II for a pection prior to grouting and a final inspection. /'�,,, <br /> Signed X I e: 4 e>� / Date-. �Q <br /> (Draw Plot Plan on Reverse Sid <br /> FOR EPARTMENT USE ONLY <br /> PHASE 11 <br /> Application Accepted By <br /> z <br /> � Date 7 �� <br /> Additional <br /> Comments: <br /> Date <br /> Inspection Phase lit Final Inspection'. { <br /> Inspection By e o /3-90 )0-7-YC <br /> G — _ Inspection By � ate <br /> fpr i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT yot-PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION .BILLING REMITTANCE $ AMOUNT DUE CHECKED +' <br /> DATE DATE REMITTED <br /> �i AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER ^" <br /> •F,..K OTHER .. ._ �. <br /> 7-6 <br /> Received by Date Receipt No, Permit No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO,, ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />