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I ApplicationsWill 8e Processed When Submitted Properly Completed. Be Sure To Sign The Application." <br /> :J OR OFf;CE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&W <br /> ENVIRONMENTAL HEALTH PERMIT �I-L <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/ r" <br /> o Install the work herein described.This application is j <br /> made in compliance with San Joa uin County Ordinance No. 1862 an he rules and regulations of the San Joaqui Local Health District. <br /> Exact Site Address O e _ City/Town /�/� _e� ` <br /> 1�. <br /> Owner's Name e t" <br /> Phone <br /> Address f <br /> City— <br /> Contractor's Name Licenso# <br /> Contractor's Address �t:� 5—�� Business Phone <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes DC - No <br /> TYPE OF WORK (CHECK): NEW WELL IR DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> P Sewer Lines Pit Privy �^ <br /> Sewage Disposal Fie#d — Cesspool/Seepage Pit Other <br /> Property Line,_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ � DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC <br /> DRIVEN Gauge of Casing , <br /> IRRIGATION 0 GRAVEL PACK Depth of Grout Seal M <br /> ❑ CATHODIC PROTECTION 54 ROTARY Type of Grout h <br /> ❑ DISPOSAL ❑ OTHER <br /> ❑ GEOPHYSICAL Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Gontrac#or <br /> Type of Pump d <br /> PUMP REPLACEMENT: [] H. <br /> -state Work bone �t <br /> PUMP REPAIR: ❑�State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure S <br /> ? I <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. <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, 1 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 forwhich this } <br /> permit is issued, I shall emp rsons subject to workman's compensation laws of California." <br /> will r a Gro Ins p to grouting and a final inspec ' <br /> Signed X <br /> Title: _ Date: r <br /> Il. (Draw Plot Plan on Reverse Side <br /> F R DE ARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By i <br /> Additional Comments: Date <br /> Phase II Grout Inspection Phase ill Fi I Inspection t <br /> Inspection By Date Inspection By <br /> Date Inspection <br /> Is Due: ❑ ANNUALLY ❑ PER.UNIT PER SITE ❑ EACH [] Januar 1 &Re <br /> 4 Y d By January 31 El July 1 &Received By July 31 J <br /> BASE EXPLANATION BILLING REMITTANCE $ REM{T �1 <br /> DATE DATE REMITTED AMOUNT DUE CHECKED I <br /> S FEE <br /> AMOUNT <br /> LESS <br /> 4 PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> I <br /> I OTHER <br /> i <br /> Received by Date Recei t No <br /> ' P Permit No. Issuance Date Mailed Delivered 1 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE„P.O.Box 2009 5TOCKTON,CA 95201 7 <br />