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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F.O1r8ffWE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> _ PUMP&WELL <br /> —-- ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District orapermit toconstruct and/or install the work herein described.This application Is <br /> made in compliance with Sa oa uin County Ordin nce No. 1.862 and th rules and regulations of the San aquin Local Wealth District. <br /> Exact Site Address rf City/Town � /Tz5? -f <br /> Owner's Name Phone _ <br /> Address � City <br /> Contractor's Name GfJ 1. Li ease# / Business Phone <br /> Contractor's Address Emergency Phone 0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _..__.` 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 /> Property Linel Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> 1t' 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 urf ce Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P, <br /> PUMP REPLACEMENT: DI State Work Done OCA <br /> PUMP REPAIR: ❑iState Work Done f <br /> DESTRUCTION OF WELL: Well Diameter <br /> II Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that 1 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a-final inspection. <br /> Signed X IG� Title: j:. <br /> " a <br /> (Draw Plot Plan on Reverse Side) Date: <br /> f <br /> - FOR DEPARTMENT USE ONLY 1 <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: I <br /> Phase II Grout Inspection. ase 111 Fin Inspection <br /> Inspection By rf D � u✓%� <br /> � ( ate Inspection B Y fe>�� "Date ///z—JV ( <br /> Fee IS Due: ❑ ANNUAi-LY ❑ PER UNIT ❑ PER SITE 1:1 EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1 AMOUNT <br /> FEE 4D <br /> LESS l) <br /> PRORATION <br /> PLUS <br /> PENALTY { <br /> OTHER { '- <br /> OTHER r <br /> 01 <br /> Received by Date -Receipt No. -Permit No. i uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENV]RONMENTAL'HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.ao:2069 STOCKTON.CA 95201 , <br />