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Applications Will Be Processed WhenSubmittedProperlyCompleted. tieSure iosign 1neApplication. <br /> .,. o oIICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> T <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto 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 Health District. <br /> f <br /> Exact Site Address� 7 S:-_/'C_ �� � �� City/Town /� .�/ <br /> Owner's Name o-�`� Phone <br /> Address City G <br /> Contractor's Name _ License !u J Business Phoneme l / ,�e/_-� <br /> / 1 <br /> Contractor's Address -3v Emergency Phone ,7p , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �r No <br /> TYPE OF WORK (CHECK): NEW WELL 'L�' EEPEN ❑ ;r-RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER El PUMP INSTALLATION L� 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 64 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> - ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I=I LJVMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing L - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION Cl GRAVEL PACK Depth of Grout Seal ~d <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout '?� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter — Approximate Depth <br /> v 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:"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 /> �Z7 <br /> Grout Inspection prior to grouting d a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> .Application Accepted By Date <br /> Additional Comments: <br /> Phase At Grout Inspection Pha III Final Inspection <br /> Inspection By Datdk711' Inspection By7 Date, <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT e <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> (y / Q <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issu ce Darte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Bax 2009 STOCKTON,CA 85201 <br />