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cons Will Be ProQQce����']]sed en Submitted Properly Completed-Be Sure To Sign aApplication. <br /> FOR OFFICE USE: �A� 1J"`' APPLICATION <br /> (For j!Ipn-Transferable, Revocable,Suspendable) PUMP&WELL <br /> SaN 1D"Q U�(ILLRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)H �'T� WATER QUALITY .. <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> 862 and the rules and regulations of the San Joaquin Local Health District. <br /> made in compliance with San oaquin County Ordinanc"o. 1 , <br /> U City/Town <br /> Exact SiteAddress•�'� :� <br /> Owner's Name /L � Phone <br /> lJ.:. ; City <br /> Address usiness Phone <br /> Contractor's Nam Licens # <br /> Emergency•Phone " <br /> Contractor's Addres No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL "DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines y <br /> Cess ool/Seepage Pit Other <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE i ❑ DRILLED Dia. o1 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 /> 13 GEOPHYSICAL Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> s <br /> PUMP REPLACEMENT: ❑--,,�State Work Done <br /> ,,i3 <br /> PUMP REPAIR: ` 5tate Work Done . <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r! <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 performanceof the work forwhichthis permit <br /> is issued, t shall not employ any person in such manner as to become subject to workman's compensation IaAof California." <br /> Contractor's hiring or sub-contracting signature cer'fles the following:"I certify that in the performance of the wor forwhich this i <br /> permit is issued, I shall employ perso subjecetworkmapg�OmPensat!Oh laws of California." <br /> I will ca for a Grout Inspectio pr' r to gro nda 1' al ' spection. - <br /> Iet _ Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - DateL—J-`u <br /> Application Accepted By r <br /> Additional Comments: <br /> as@ nallnspection6 <br /> Phase II ro I pection ate " <br /> Inspection By f <br /> ate Inspection By <br /> Fee Is Due: C) ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED' <br /> BASE, EXPLANATION DATE DATE REMITTED AMOUNT <br /> PEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY .. m• <br /> i <br /> OTHER <br /> OTHER <br /> a- Y <br /> Received by <br /> Date Receipt N0. Permit No..,. - I suance ate Mailed Delivered <br /> ,_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HA2ELTON AVE.,P.O.BOX 2009 STOCKTON,CA 9 <br />