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> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application: <br /> FOR OFFICEUSE: i APPLICATION <br /> ' (For Non-Transferable, Revocable, Su�gpendabfe) { <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL1Z9 I <br /> = _� -_ . <br /> (COMPLETE IN TRIPLICATE) y'�g p�Z _Lort t� ,q��1ATER QUALITY 2G�o"7O—`�3 <br /> Application is hereby madeto theSan Joaquin Loca!Health Districtfora permit to construct and/or instal l the work herein described.This application is r <br /> made in compliance with San Joaquin Count Ordinanc No. 1862 and the rul sand I onsDt the San Joaqui Local Health District. <br /> Exact Site Address L ' own e <br /> Owner's Name Phone ' <br /> Address City � r q <br /> Contractor's Name License# ,[/,�_ Business Phone <br /> Contractor's Address € Emergbncy Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—x No <br /> TYPE OF WORK (CHECK): NEW WELLJ� DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ , <br /> DISTANCE TO NEAREST: Septic Tank <br /> f� <br /> J Sewer Lines Pit Privy •---- - <br /> Sewage Disposal Field_&. Cesspool/Se epage Pit .----�_ Other___=_, I <br /> Property Line j�Q Private Domestic Well.S-4) 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 r❑ DRIVEN Gauge of Casing o� <br /> 11 IRRIGATION X�.GRAVEL PACK Depth of Grout Seal w <br /> ❑ CATHODIC PROTECTIONb <br /> ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 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: 0 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, J4 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 11 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California," O <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this '1% <br /> permit is issued, I shall empigy persons subject to workman's compensation laws of California." J <br /> II call fo G t In ion prior to grouting and a final inspection. 1 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By t Date <br /> Additional Comments: <br /> hase�If Grout Inspection tt� hase If[ Final Inspection <br /> Inspection By ` j�1[ 1 Date -15910 Inspection B Date ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ EACH ❑ January"! &Received By January 31 ❑ July 1 &Received By July 3133 <br /> BILLING REMITTANCE $ REMIT !I <br /> BASE EXPLANATION A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT I <br /> FEELP <br /> LESS <br /> PRORATION F <br /> PLUS <br /> PENALTY <br /> OTHER u <br /> -tom` ii <br /> OTHER <br /> 1 <br /> . Received by" - Date ' ; Receipt No. Permit No. Issuance Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200952"/STOCKTON,CA 9 3�b M <br />