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ApplicationsWill Be Processed Wkn Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferabie, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 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 San Jo um County Ordinance No. 1862 and the rules and regulations of the San az Local Health District. <br /> Exact SitAName <br /> City/Town <br /> Owner's Q"/�/311 Address PhoneCity <br /> ContractLicense#� 4 <br /> Business Phone <br /> Contractr Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCT O� J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST; Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspoo[/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 <br /> E] DOMESTIC/PUBLIC 11 DRIVEN <br /> a of C Casing <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ Type of Grout 4 <br /> DISPOSAL <br /> ❑ OTHER f. Other Information <br /> ❑ GEOPHYSICAL 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: <br /> Well Diameter—._ IR ._ � Approximate Depth <br /> Describe Mater' and Proced re <br /> I hereby certify that I.have prepared this application and that the work will be done in accordance with San Joaquin County a <br /> ordinances, state Jaws, 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 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 call for a Grou Inspect prior to grouting and a final inspection. <br /> Signed X t Title: <br /> Date: <br /> n� <br /> (Draw Piot Plan on Reverse Side) <br /> PHASE I M <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted By r�� /„�_Q�. <br /> Date <br /> Additional Comments: <br /> Phase fl Grout Inspection hose !II Final Inspection <br /> Inspection By-- <br /> y Date Inspection By Date <br /> Fee is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> n <br /> BASE ,EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMDUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by �. Date Receipt No � ��� <br /> P Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />