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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) G <br /> i. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY l gs-—(So rOs <br /> 1 <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 compli nce with San Joaquin County Ordina 1862 and the rules and regulations of the San Joaquin Local ,H alth District. <br /> Exact Site A( City/Town 44irl <br /> & <br /> Owner's Name fC Phone � � JAI r <br /> Address City / <br /> Contractor's Name �+� �� License# Business Phone !� ^�s <br /> Contractor's Address :2-,E y` ' Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ n No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION IT DESTRUCTION❑ pn <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ t <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 /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ® j <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ] <br /> ❑ DOMESTIC/PUBLIC I? DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑i GRAVEL PACK Depth of Grout Seal <br /> ■ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL f 12 OTHER Other Information <br /> GEOPHYSICAL g�` � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor:T <br /> Type of Pump H.P. <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 /> Homeowner or licensed agent's signature certifies the following:A 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 sup-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 /> a4n6-,fpection prio o grouting and a final inspection.Signed X Title: �� Date: ,,z � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By � � Inspection By Date <br /> 1 <br /> 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 /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS {- <br /> PRORATION i1 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k� <br /> 4 <br /> y OTHER <br /> a <br /> Received by Date 11 Receipt No, Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL FIEALTH PERMITISERVICES 1601 E.HAZELTON AYE., ox 2009 STOCKTON,CA 45201 <br />