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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application._ <br /> I-004FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> . ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> .eL- NRCATE) WATER QUALITY <br /> k Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> t made in compliance with/5 oa in County OrdjLroncebo. 1862 t r nd regulations of the San J a al a 1s <br /> Exact Site Address / � 1�� �= City/Town <br /> ,. <br /> Owner's Na Phone <br /> Address G z City <br /> Contractor's Na a [.4 J �, License 93'/UZ_-6usiness Phone 17 J"!!_7 `r<<`7� <br /> Contractor's Address V /p Emergency Phone <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 9--'PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> j 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 /> ❑, QQMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> iR IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL E] OTHER Other Information <br /> r ❑ GEOPHYSICAL Surface Seal Installed By: f <br /> I PUMP INSTALLATION: Contractor V <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> 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 /> Contractor's hiring or sub-contracting signature ce !ties the following:"I certify that in the performance of the work forwhich this <br /> ( — <br /> permit I sued, I shall employ per ns bject workman's compensation laws of California." <br /> I wil al for a Grou ins ection p or ro g and a final aspect' <br /> Signed X Title: Date: <br /> (Draw Plot-Plan on Reverse Side) <br /> FDR DEPARTMENT USE ONLY <br /> y <br /> PHASE I <br /> "Application Accepted Date <br /> Additional Comments: <br /> Phase Ii Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date /.� 005 <br /> Fee Is Dile: ❑ 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 PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> -FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY�� <br /> I - <br /> OTHER <br /> OTHER <br /> Received by. Date Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO:Z ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 952131 <br />