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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 1 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> A SEN R�ONNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) /�l�. c-,�CJ TER�I�L'ITT 6�#r <br /> Application is hereby made to the San Joaquin Local Health District for aper`mi totconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compiianc with San Joaquin Ordinance No. 1862 ar the�rules-and regul tiet#Wbf the Sa54Daquin Local Health District. <br /> Exact Site Ad �_ U ��- � �f Ga9 A- <br /> Owner's Nam w Phone <br /> Address City <br /> 4 �} e <br /> Contractor's Nam ��usiness Phone 6� �� <br /> I' 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❑ DESTRUCTIO,�N,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER 11 6N PUMP INSTALLATION IS 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 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑,DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN , Gauge of Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑,OTHER-- Other Information <br /> C ❑ GEOPHYSICAL Surface Seal Installed By: <br /> i' PUMP INSTALLATION: Contractor <br /> Type of Pum <br /> p• H.P. <br /> PUMP REPLACEMENT: r ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> ^ DESTRUCTION OF WELL: Well Diameter--^- Approximate Depth <br /> Describe Material and Procedure 7 <br /> o <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 forwhich 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 /> .on <br /> s hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permi s ' ,ed, I shall employ person ubj to wo man's compensat' n laws of California." <br /> Iwi ca for a Grou Inspeectiion prior gr ting a final insp L <br /> Signed X GC/� Title: Oate: �� 1 <br /> (Draw Plot Plan on Reverse Side) f <br /> } FOR DEPARTMENT USE ONLY <br /> i PHASEI <br /> 4 Application Accepted By z Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection B� �� F] <br /> Datq <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Bl�Jul�y 1 &Received 8y July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Lu� <br /> + U O <br /> j LESS <br /> IL PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />