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.� Applications Will Be Processed When Submitted Properly Completed. BeSureTo5ign TneApplIC0111110111. <br /> 3 APPLICATION <br /> FDR OF <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL-- <br /> ENVIRONMENTAL HEALTH PERMIT_ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSanJoaquinLocalHealthQistrictforapermittoconstructand/or install the work herein described.This application-ii r <br /> made in compliance with San Joaquin),Cou ty Ordinance No•1 862 nd e rut and regulations of the San Joaquin Local He Ith District. <br /> City/Town �� <br /> Exact Site Address <br /> Phone l <br /> Owner's Name c ! <br /> City ti <br /> Address F /r <br /> Contractor's Name if", lip <br /> License Business Phone <br /> �} Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes n <br /> TYPE OF WORK (CHECK: NEW WELL DEEPEN ClRECONDITION 13DESTRUCTION13 <br /> WELL CHLORINATION 1:1WELL ABANDONMENT 1:1OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ s <br /> DISTANCE TO NEAREST: Septic Tank' Sewer Lines � �� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit c!_�) Other <br /> Property Line Private Domestic Well gii Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> �60MESTIC/PRIVATE Ir -l]I'SILLED Dia. a Well Casing <br /> 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑,� CGGRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION 0, OTARY Type of Grout <br /> E] DISPOSAL ❑ OTHER Other Information i r , <br /> 11 GEOPHYSICAL place Sial nstalled By: . <br /> PUMP INSTALLATION: Contractor r <br /> x Type of Pump g. N.P.. <br /> r <br /> PUMP REPLACEMENT: ❑ State Work Done I'b <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: k <br /> Describe Material and Procedure <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 /> Home owner 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 /> t. <br /> I or s tion prior to grouting and a final inspection. <br /> Signed X Tiile: Date: <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I O Date <br /> Application Accepted By <br /> Additional Comments: =1 <br /> Phase 11 Grout Inspections— �} Phase III final Inspe 'on <br /> Date `� Inspection B to <br /> Inspection By T� - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January 1 &Received By January 31 JuVy 1 &Recely d By REMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED +p�Q AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER <br /> . J <br /> { _ - Permit No. ssua ce Date Mailed Delivered <br /> Received by Date Receipt No <br /> '""r'APPLICANT=RETURN ALL COPIES TO:I. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />