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Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppncauon. ,1 <br /> FOR OFFICE USE: ` APPLICATION <br /> (For Non Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <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 t�rule and regulations of the San Joaqui_ ca N aith District. <br /> Exact Site Address h 10 City/Town <br /> Owner's Name �p�- Phone <br /> Address City <br /> Contractor's Name <br /> License If Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ V <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 Weil <br /> 4 <br /> INTENDED USE TYPE OF WELL <br /> 113 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _ <br /> A� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor �D� �"`� A <br /> or <br /> Type of Pump k 1P"`S°r H.P. r <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done_ <br /> PUMP floppm: State Work Done J <br /> DESTRUCTION OF WELL: Well Diameter pproximate 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 /> 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." <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 w I call for Grout Inspect* n ri t grou ' g and a final inspection. <br /> Signed Ille: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE 1 <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection P e I nal Inspection /J rJ ._ <br /> Inspection By Date inspection By Date 7 <br /> i <br /> Fee IS Due: C3ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary 1 & e eived By January 31 ❑ Juiy 1 &Recely REMITd By uiv 31 <br /> I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 4 S <br /> LESS <br /> PRORATION J <br /> PLUS <br /> PENALTY <br /> u LAG <br /> OTHER 1 v L <br /> I <br /> OTHER <br /> ` Date Receipt No, Permit No. Issu nce ate Mailed etivered <br /> Received by JJ <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON" <br /> F <br />