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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: I; APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY, .,t <br /> (COMPLETE IN TRIPLICATE) <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local H I h District. <br /> Exact Site Address , <br /> City/Town <br /> s. <br /> Owner's Name '1� Phone <br /> rr `8`� <br /> Address ��--�� —+ <br /> Contractor's Namet'License# '�7_�r Business.Phone <br /> Contractor's Address t <br /> Emergency Phohe �' "�~ L <br /> Is Certificate of Workman's Compensation Insurance on FileWith JLHD? Yes_ _� No - I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ 'DESTRUCTION❑ 0d <br /> WELL,CHLORINATION 0 WELL ABANDONMENT-0 OTHER ❑� PUMP INSTALLATION ❑ PUMP REPAIR �, 1 <br /> REPLACEMENT❑: d <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 /> [IINDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE :I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 7 ❑ GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL !i ❑ OTHER Other Information <br /> 11GEOPHYSICAL y Surface Seal Installed By: - - <br /> PUMP INSTALLATION: liContractor' <br /> fA Type of Pump H.P. <br /> PUMP REPLACEMENT: >i ❑State Work Done— <br /> PUMP REPAIR: <br /> ® State Work Done ir <br /> F DESTRUCTION Ol WELL: II WellyDlameter - ` Approximate Depth <br /> l.= Describe Material and Procedure <br />{ <br /> [ 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 Jbaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the f6llowing:1 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 /> f Contractor's hiring or sub-contracting signature certifies the following:".I certify that in the performance of the work for which this <br /> k permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Alwilftall for a Grout Inspectio rio to u I and a lnal inspection. <br /> Signed X e: Dale: <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY � � l <br /> PHASE 1 s Date <br /> i Application Accepted By <br /> Additional Comments: <br /> i Phase II Grout Inspectlon —Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> a <br /> I Fee Is Due: ❑ ANNUALLY ' ❑ PER-UNIT -❑ 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 /> A DATE DATE REMITTED AMOUNT <br /> l FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER * i <br /> Receipt .. <br /> Received by Date 'p Permit No. Is uance Oat Mailed Delivered' <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />