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`r Applications Will Be Processed When Submitted Properly omp e e . <br /> APPLICATION <br /> FQR OFFICE USE: I <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br />'f (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/onnstall the work.herein described,This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations <br /> of the San Joaquin Local Health District. <br /> Exact Site Address <br /> A Phone <br /> Owner's Name City <br /> AddressPhone <br /> Contractor's Name /+/ a< License# ���usiness 1; i <br /> Contractor's Address �f d f �► Emergency Phone <br /> l No , <br /> Is Certificate of Workman's Compensation I,n�surance on File With SJLHD? Yes��— . <br /> TYPE OF WORK (TION K❑) WE W A8 ABANDONMENT ❑DEEPEN ❑ OTHER 13 ITIOp❑P INSTALLATION ❑❑ PUMP REPAIR❑ <br /> WELL CI-fLORINATlO <br /> ` REPLACEMENT❑ --�— <br /> DISTANCE TO NEAREST: Septic Tank es 'S-o Pit Privy <br /> – Sewer Lin <br /> Sewage.Disposal Field <br /> ' Cesspool/Seepage Pit ��- Other <br /> Property Line_ f�Private Domestic Well/�d Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> �. CABLE TOOL""` Dia."ofi Well Excavation—�a� F' � n <br /> ❑ INDUSTRIAL Y <br /> ❑ DRILLED Dia. of Well Casing <br /> .K DOMESTIC/PRIVATE Gauge of Casings <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN <br /> ` ❑ GRAVEL PACK Depth of Grout Seal <br /> 13 -IRRIGATION <br /> Type of <br /> 13 CATHODIC PROTECTION 13 ROTARY 11 DISPOSAL. 11 OTHER Other Infformaorma <br /> tion <br /> Surface Seal installed By: <br /> 13 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> I Type of Pump <br /> l PUMP REPLACEMENT: ❑ State Work Done <br /> k Done <br /> El State Work PUMP REPAIR: ate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and P ocedure <br /> I hereby certify that I haverepared 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 /> Nome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for whichthis 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 /> l Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work forwhi11hs <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection pri r to grouting and a final inspection. <br /> Title: 2� Date: <br /> Signed X <br /> yo <br /> (Draw Plot Plan on Reverse Side) �_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Dat <br /> Application Accepted By <br /> : <br /> Additional Comments <br /> � Fhas Iii Final inspection <br /> PhJRe 11 Grout Ins�}ection <br /> Inspection By <br /> Date / Inspection By °.`�CJ� <br /> Fee Is <br /> Dile: 13 ANNUALLY [3 PER UNIT ❑ PER SITE r[IEACH ❑ January 1 &Rec�ive:By ❑ duly 1 &ReceivedByJuly 31 <br /> 3. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> a <br /> r FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 4 <br /> OTHER �l <br /> Received by Date <br /> Receipt No. Permit No. issuance Date Mailed Delivered <br /> I _ <br /> ' . TISERVICES <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMI1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />