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Applications Will Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFFIC". SE: APPLICATION <br /> .. (For Non-Transferable, Revocable, Suspendable) t <br /> PUMP&`WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i <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 with San Joaquin County Ordinan No. 1862 and the rule_s and regulations of the San Joaquin Local Health District. <br /> r Exact Site Address_ �! .30 <br /> Oelt City/Town <br /> r. <br /> t Owner's Name Phone <br /> Address tS� City <br /> Contractor's NameLicense#. ��f 7f_ Business Phone'� � /Ll <br /> Contractor's Address O E '— <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W' h SJLHD? Yes 1- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN O <br /> WELL CHLORINATION El WELL ABANDONMENT El OTHER El PUMP INSTALLATION 6-- PUMP REPAIR❑ <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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Q-D­OM�STIC/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 n <br /> 1 ❑ GEOPHYSICAL Surface Seal Installed By: yJ <br /> i PUMP INSTALLATION: Contractor ` r <br /> Type of Pump L4,t - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure (/1` <br /> f , <br /> i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 'Ft'i� for�Grout�Inspection prior to grouting and a final inspection. <br /> Sig d X . Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY R <br /> PHASE I <br /> Application Accepted By _ Date/,Z_ 3 �J_-a "} <br /> Additional Comments: <br /> Phase 11 Grout Inspection "Se III Final ,�spectiqjy <br /> Inspection By Date Inspection By <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 5ry d d <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY <br /> OTHER <br /> S <br /> OTHER <br /> 4011 <br /> Received by - Date Receipt No. Permit No ! suanc Date Mailed Delivered <br /> _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- - 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br /> r � I <br />