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Applications"Will Be Processed When Submitted Properly Completed. Be Sure To Sign Ttte pplication. sn <br /> ` <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALT'H'-PERMIT <br /> (COMPLETE IN TRIPLICATE WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin.County Ordinance No. 186 and the ruies.and reg lations of the San�Joaquin Local Health District. <br /> Exact Site Address City7Town ei <br /> Owner's'Name 111— Phone CSS�C O. <br /> Address City <br /> w <br /> Contractor's Name �'� � - - t � t. }' License' Business Phone' <br /> Contractor's Address { - _ ' Erriergency Phone 4 "'` ' ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes G ` No <br /> TYPE OF WORK-(CHECK): NEW WELL❑� — DEEPEN ❑: "" RECONDITION 13 —DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 .PUMP INSTALLATIONUMP REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Y Septic Tanks ' 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 /> ❑ IRRIGATION f ❑ GRAVEL PACK 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: I Contractor ' <br /> Type of Pump. ' H.P. f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done S <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t.. Describe Material and Procedure <br /> I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I ordinances, state laws, and rules and regulations of the San Joagjlin 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 <br /> I lLcal Cdr Grout�i � <br /> n prior to grouting and a final inspection. - <br /> m Signe Title: v CJw�=GJ�� Date: <br /> 1 g (Draw Plot Plan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase If Grout Inspection mal Inspe on 7� <br /> Inspection By Date Inspection By 4winate. <br /> 3. s <br /> Fee Is Due: ❑ ANNUALLY 1 ❑ 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 /> �jr� DATE DATE REMITTED AMOUNT <br /> FEE / 6 <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> k 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 />