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Applications Will Be Processed When Submitted Properly Completed.'Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <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 LocalHealthDistrictforapermit toconstruct and/or install the work herein described.This application is <br /> f made in compliance Sa nJoa n County Ordinance No. 1862 and the rules and regulations of the San a uin Local Health District, <br /> Exact Site Address_L '�°.. ��'�00 F _ City/Town <br /> Owner's Name Phone <br /> Address 1P,,PO Z, City <br /> Contractor's Namel 2 License# Business Phone <br /> r Contractor's Address <br /> Emergency Phone ~1�5 6 <br /> Is Certificate of Workman's Compensationns rance 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 REPAIR yyyl <br /> REPLACEMENT❑ ;U <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy \4w <br /> Sewage Disposal Field Cesspool/Seepage Pit Other v, <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 10` <br /> DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing [fir <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal se 01 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br />€' ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL kl 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 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 /> I3' r ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit CJI <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." j <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 Grout Inspection prior to grouting and a final inspection. 1 <br /> Signed X .. Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l � 1� r 16_81 <br /> Application Accepted By �y� _ Date <br /> Additional Comments: <br /> ha a 11 Grout Inspection Phwiie III Final Inspection <br /> Inspection By Date k- S? Inspection By DatedzL�— <br /> R <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 j <br /> BASE EXPLANATION BILLING REMITTANCE .$ REMIT I <br /> DATE T REMITTED AMOUNT DUE CHECKED , <br /> 1 AMOUNT <br /> dc7 I. D� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .. . <br /> OTHER <br /> OTHER ..._. <br />\ WAPPCAYIT—IETURN <br /> Date -f Receipt No. Permit No Issuance Date .Mailed Delivered ' <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 ' <br />