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_ pplications 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 /> 1 <br /> (COMPLETE-IN TRiPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application is f <br /> made in compliance with San Joaquin County Or inance No. 1862 and the rules and re uI. ions of the San aquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Nam Phone Q <br /> Address City i <br /> Contractor's Name icense#„ 77 Business Phone <br /> Contractor's Address Emergency Phone ' <br /> Is Certificate of Workman's Compens Ion Insur ce 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❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit - r Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE T�FPE OF WELL ` J/ <br /> ❑ INDUSTRIAL P CCABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTiC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> �❑,, <br /> DOMESTIC/PUBLIC C1 DRIVEN Gauge of Casing <br /> IWiRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL L f <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <br /> Describe Material and Procedure <br /> �x <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 arid: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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca t a Grout Inspecti for t grouting and a final Inspect�I n._ <br /> Signed X Title: —2 .v Date: <br /> w Plot Plan on Reverse Side) # <br /> FOR DEPARTMENT USE ONLY +� <br /> PHASE - - <br /> Application Accepted By Date — � <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final I spection f <br /> Inspection By Date Inspection By Date <br /> Y �: ,�-.16- 1 <br /> •:Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 } <br /> _ <br /> BASE e'EXPLANATION <br /> BILLING REMITTANCE $ REMIT <br /> A. y+�-a� --- DATE 4'REMITTED - AMOUNT DUE CHECKED <br /> +� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION •- <br /> PLUS <br /> PENALTY _ i :.�= s .„�� �. •£ t.. a-�..,,....s3. i -y <br /> OTHER <br /> f� <br /> OTHER <br /> 04, <br /> Received try Date Receipt No. Permito.No. `Issuance Date Mailed [Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIIYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />