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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> +CR OFFICE USE: I ' APPLICATIONS <br /> (For Non-Transferable, Revocable,Suspendable) <br /> - PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY a <br /> Application is hereby madetotheSa' Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County ,Oinance No. 1862 and tJLe ules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 's �' City/Town <br /> F - <br /> Owner's Name r / Phone <br /> Address _ VM - City <br /> Contractor's Name License# d Business Phone _ �- � t <br /> Contractor's Address P, Emergency Phone —� <br /> Is Certificate of Workman's Compensation/Insurance on File With SJLHD? Yes No A0 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ T <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t <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 /> VDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casingf <br /> ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> :J <br /> ❑ GEOPHYSICAL Surface Seal Installed By: s J <br /> PUMP INSTALLATION: I Contractor <br /> i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ 0 42 A <br /> PUMP REPAIR: X State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> zr <br /> i Describe Material and Procedure i <br />' I <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 /> 'i. <br /> Home owner or licensedlagent'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 sb-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 /> g I will call for a Grout Inspection prior to grouting and a final insp on. �—_ <br /> Signed X Titlef — — Date: <br /> (Draw Plot Plan on Reverse Side) <br />[ d! FOR DEPARTMENT USE ONLY r <br /> i PHASE I <br /> Application Accepted By Date <br /> I Additional Comments: <br /> Pt>dse II final Inspection If Grout Inspection <br /> Inspection By �� Date Inspection By Date <br />{ Fee Is Due: ❑ ANNUALLY I ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I�I <br />' BILLING REMITTANCE $ REMIT <br /> BASE117EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION J� <br /> PLUS <br /> PENALTY r <br /> OTHER II <br /> OTHER <br /> 144 Received by Date Receipt No, Permit No. Issuanc Date Mailed Delivered i <br /> —RETURN ALL COP ES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br /> _! <br />