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_tet- Applications Will Be Processed When Submitted ProperlyCompleted. Sesure IoWgn Iner+ppn1-anv„• <br /> FOR OFFICE USE: r APPLICATION y <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> i <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work.herein described.This application is <br /> made in compliance with San Joa uin Co ty Ordinance N . 1862 and the rules and regulations of the San Joaquin Lo al Health District. <br /> I <br /> City/Town <br /> I Exact Site Address” <br /> Phone : <br /> Owner's Name <br /> Address 1111 <br /> City <br /> Contractor's Name License#'�� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes.�Y No <br /> TYPE OF WORK (CHECK): NEW WE'L1:1L DEEPEN ❑ RECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Er PUMP REPAIRS r n <br /> REPLACEMENT❑ 0 - , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> `44 Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1 Property Line Private Domestic Well Public Domestic Well <br /> F <br /> INTENDED USE TYPE OF WELL <br /> i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �h <br /> ❑ CATHODIC PROTECTION ❑ ROTARY r Type of Grout <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: y Contractor' <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done L <br /> DESTRUCTION OF WELL: <br /> 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 /> j 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, I 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 employ persons subject to workman's compensation laws of California." <br /> i <br /> k I will�all �Grou�Inc=onprior to grouting and a final insp ion. <br /> Signed X -�^ Title _ Date: 2 <br /> (Draw Plot Plan on Reverse Side) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE 1 QL Date —� <br /> Application Accepted By r � <br /> Additional Comments: <br /> Phase II Grout Inspection Ph e u Final Inspection <br /> { Date Inspection By Date <br /> Inspection By <br /> f <br /> I. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 , eceived By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> 64L1-ING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> - F <br /> OTHER q <br /> ` 4 <br /> .Iss Mailed Delivered <br /> Received by <br /> D [e Receipt No. � Permit No. = ante Dae <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2099 STOCKTON,GA 95201 <br />