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'~ Applications Will Be Processed When Submitted ProperlyCompletes rse sure iosign inesappncaacvri. <br /> FPR 4FF!E USE: APPLICATION <br /> i <br /> or' (For Non-Transferable, Revocable, Suspendable) PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY R <br /> Application is hereby madc*to the San Joaquin alHealth District for a permit to construct and/or install the work herein described.This application is <br /> m an�an Joaquin Countrdinance No. 1862 and the rule an re ul i ns of the San Joaquin Lo' al Hfalth District <br /> Exact Siteress City/Town <br /> Owner's Name <br /> Phone � �� � S <br /> A 1 City � <br /> Address <br /> Contractor's Name e _ � License � cP Business Phone l 1 <br /> Contractor's Address 7 t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> G'. <br /> TYPE OF WORK (CHECK): NEW WELL-""DEEPEN ❑ -RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑� OTHER E]- ''PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT El ���` <br /> DISTANCE TO NEAREST: Septic Tank - I Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other Al <br /> Property Liner 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 01. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> —IRRIGATION 13., GRAVEL PACK Depth of Grout Seal <br /> 13 ,, <br /> � <br /> CATHODIC PROTECTION RGR�OTARY Type of Grout - <br /> ❑ DISPOSAL —[ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work"Done <br /> PUMP REPAIR: ❑ State Work 6.one" - - ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> d _ 1 Describe Material and Procedure <br /> . + n <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, aisd 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c ora ut Inspection prior to groutin d a final inspection. Q <br /> Signed X Title: *_.._.. _ Date: <br /> (Dr lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I SCJ f <br /> Application Accepted By LJ Date _ D I <br /> rvv <br /> Additional Comments:_ � — <br /> Phase H out Inspection P se Fi Inspection 3a <br /> Inspection By Date Inspection�y e �B� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT� ❑ PER SiTE ❑ EACH f ❑ January 1 &Received By January 31 ❑ July i &Received y July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE. REMITTED AMOUNT <br /> FEE r <br /> LESS j <br /> PRORATION - <br /> PLUS <br /> PENALTY y} <br /> OTHER * t # R <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />