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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 anId thIaptes and regulations of the San Joaquin Local Health District. ' <br /> Exact Site Address 7 i City/Town <br /> Owner's Name �� Phone <br /> Address ' , j ` City_ a.'a ' <br /> Contractor's Name d' License#/ Business Phone —7i <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> TYPE OF WORK (CHECK): NEW WELL2� ' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ;L C1 C`!, Sewer Lines ;4 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line/. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f w <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 2-ROTARY Type of Grout <br /> ❑ OTHER ' Other Information <br /> ❑ DISPOSAL - <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor < 4�r Q -z,A.%"I <br /> Type of Pump S" 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 /> xi ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"(•certify that in the performance of the work for which this permit <br /> f °r is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> L � � <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 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. <br /> Signed X �[ l > - .�"! "� Title: Date.- <br /> (Draw Plot Plan on Reverse Side) <br />{ r , <br /> F FOR DEPARTMENT USE ONLY <br /> I PHASE 1 <br /> Application Accepted By'�I � <br /> Additional Comments: <br /> sq'if G t Inspection ha 111 Final Inspection <br /> #Inspection By Date 1(/ it Inspection By 41 <br /> 9 Date <br />' � J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1'&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> F 4 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ri- Received y1y Dat `- Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> .� GPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />