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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign TheApplication. <br /> FOR 2 FICE usE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) y <br /> PUMP&WELL I <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 <br /> made in compliance w t a Jo ulty O inance 62 and the rules and regulations of the San Jy� I District. <br /> Exact Site Address �• City/Town /�/ 6 ) <br /> Owner's Name `' " Phone <br /> Address � City <br /> Contractor's Name --f../V License#77hr, <br /> _ Business Phone <br /> Contractor's Addres Emergency Phone loytu <br /> Is Certificate of Workman's Compensation Insura on Fill h 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❑ I <br /> DISTANCE TO NEAREST: Septic Tank+ Sewer Lines Pit Privy <br /> Sewage Disposal <br /> �SFiietld Cesspool/Seepage Pit Other <br /> Property Lint}! Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL /Q S/—,, <br /> ❑ 1 USTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ D AVEL PACK Gauge of Casing <br /> ❑ IRRIGATION Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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—L <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 9 <br /> Home owner 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." r�vj <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 III call for Grout Inspection priAr to grouting and a final inspection <br /> / C�-fJy,�11 <br /> Title: Date: <br /> Signed X V <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ? j <br /> Application Accepted By� Date { <br /> Additional Comments: <br /> h se 11 Grout inspection Ph a a III Final Inspection <br /> Inspection By Date�C� l ` Inspection By 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 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Vale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-"AZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />