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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> w (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> OF <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 wiT San Joaquin Coun!y Ordinance No. 1862 d the rules and regulations of the San Jo uin Lo I Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Ad d ress A ZE City <br /> Contractor's Name License# Business Phonek26 p� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No j <br /> TYPE OF WORK (CHECK): NEW WELL P DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank 5go t _ Sewer Lines Pit Privy <br /> Sewage Disposal Field_ - <br /> /aO/4 Cesspool/Seepage Pit ----- Other <br /> Property Line& ff Private Domestic Well � Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ <br /> CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing f' <br /> ❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing CI.aSC <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal O I <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 05 224'r A4 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C&t�lr� <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 Q <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:"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 emplo persons subject to workman's compensation laws of California." <br /> I wit all for Gr Ins "c on prior to grouting and a final inspection. J / <br /> Signed X Title: Date: / f <br /> (Draw Plot Plan on RevEfrje Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By01LQ�ADate <br /> Additional Comments: <br /> P a II Grout Inspection +� Pbasp III l Inspection�y <br /> Inspection By\ " ' � Dates"` r.✓ Inspection 8y FinaDate <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 43 O� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t� <br /> Received by {late Receipt No. Permit No. I suance Dfite Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />