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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - — <br /> FOR OFFICE USE: Applications <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 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 /> made in compliance with S1. <br /> an Jopiquin Count Ordinance No. 1L�2 and the u s and regulations of the San Joa uin L Cal Health District. <br /> Exact Site Address City/Town c <br /> Owner's Name <br /> Address Phone <br /> cl <br /> City ph <br /> Contractor's Name icense# C <br /> Business Phone ` j <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN E] No <br /> RECOINDITIONEig DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 1� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _� * Sewer Lines <br /> Pit Privy r1- <br /> Sewage Disposal Field Cesspool/Seepage Pit r Other <br /> Property Line Private Domestic Well t Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC DRIVEN Gauge of Casing C_A ,�S ll <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ��— <br /> ❑ CATHODIC PROTECTION ROTARYa <br /> El DISPOSAL Type of Grout Cf <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 <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 forwhich this permit <br /> is issued, 1 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 employpersons sub' t to workman's compensation laws of California." <br /> I will for a Grou spec. prior uting and a final inspection. <br /> Signed X <br /> Title: Date: c <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMEN USE ONLY <br /> PHASEI �+ 1 <br /> Application Accepted By ✓k +� Date V r e4 <br /> Additional Comments: <br /> Phase 11 Grout Inspection P ase Ill Final Inspection rr�� <br /> Inspection By Date Z Inspection By Date V <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jufy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> - <br /> LESS L� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No Permit No, Issuance Date Mailed—Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1807 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />