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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application <br /> FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> �TRIPLICATE) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COM L E IN WATER QUALITY <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 an Joaquin Pgunty(Ordinance No. 862 and�the rules and regulations of the San J AquinQLocal Health District. <br /> Exact Site Address__ _ " —, ✓` vL City/Town o-, `e <br /> 7 Le <br /> Owner's Name �- r ' Phone i7 <br /> Address City ' <br /> Contractor's Name ��C'-P-t �` — License#�`.�-' % Business Phone_ <br /> Contractor's Address / - � - Emergency Phone ��' T/� —•� <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 REPAIRER" <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 /> 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 _ rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpT H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: D State Work Done r%�! �' , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ` <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 t=., <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 T <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 /> I will all fora Grout Inspection prior to grouting and a final inspeption. n <br /> Signed X � /� -_ i.Title: LDate:L <br /> U� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY % <br /> PHASE <br /> Application Accepted By Date ! <br /> Additional Comments: <br /> Phase II r Inspection, Aa4sellFi Inspection <br /> Inspection By Date Inspection By e <br /> 7 `�� <br /> a <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4 'I_ \�-7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> n <br /> � � <br /> Received by Date Receipt No. Permit No. Istsuancb Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />