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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR eFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) - , <br /> PUMP&WELL *? <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY :J <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaqui County Ordi ce No. 1862 and the r s `�d regulations of the San Joaquin Local Health District. <br /> i Exact Site Address}} �'? City/Town f <br /> Owner's Name 11Ci4eC t/r¢' -. �7�—rw�C` � Phone,?5 J / z 0 <br /> 13 <br /> Address City <br /> Contractor's Name License#/ Businesshone <br /> Contractor's Address r _ Emergency Ph ne <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR- : <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> d I <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> � <br /> ks DOMESTIC/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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> f PUMP REPLACEMENT: ❑ State Work Done 4j <br /> E PUMP REPAIR: State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter j Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> r 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 I wlit call for a Gro t Inspection prior to grouting and a final inspectio II <br /> Signed X Title; ^�� Date: <br /> (Draw Piot Plan on Reverse Side) <br /> ..J <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> I <br /> Application lAccepted By? Qmr_e� Date <br /> I Additional Comments: r <br /> Phase II Grout Inspection Ptose III Final Inspection�� <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY .. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 $ Received By July 31 <br /> REMIT <br /> r BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT , <br /> FEE yCl� <br /> LESS <br /> i PRORATION i <br /> I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> Received by Date' Receipt No. Permit No. I bsuance Date Mailea Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 ..STOCKTON,CA 95201 . <br /> J <br />