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pplfcallons Will Be Prot�ce ed Submitted Property Completed.Be Sure To Sign The Application. <br /> FOR OFF_ 'E USE: 4 �J APPLICATION <br /> q � (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ONMENTAL HEALTH PERMIT <br /> '�-f" DlSTR�t� . WATER QUALITY .. - <br /> (COMPLETE IN TRIPLICATE -'f- ..,I. <br /> r �L <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862, nd the rules and regulations of the San Joaquin Local Health District. <br /> City/Town1 <br /> Exact Site Address � � <br /> + Phone" <br /> Owner's Name <br /> I 1`y°i City" � <br /> Addressel <br /> ` Cl, fjj Bsiness Phone <br /> Contractor's Name %T / ,I License# u <br /> Emergency Phone <br /> Contractor's Address No i 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L� <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION❑ PUMP REPAIRS <br /> REPLACEMENT❑ a <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTiC/PUBLIC ElDRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> Type•of <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ' Grout <br /> ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By:. t� <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor 16,4 ! H P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Z State Work Done - ,,. <br /> 4 Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter- <br /> Describe <br /> iameter Describe Material and Procedure <br /> I hereby certify that 1 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 /> Home owner or licensed agent's signature certifies the tollowing:"I'certify that in the performance otthe 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 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 /> s <br /> I will call for a ut Inspection prior to grouting and a final inspe <br /> k Signed X7L Title: Date: <br /> r (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE I \ 1. 1J <br /> Date � �~ <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection ��Z <br /> 111 Date Inspection By Date <br /> k Inspection By -�-t�_ r, <br /> F Fee Is Due: ❑ ANNUALLY ❑ PER UN4T Cl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> i PENALTY <br /> OTHER ~ <br /> OTHER <br /> l • Da " ermIssuance Date Mailed Delivered -- <br /> Received by Date ' Receipt No., SERV No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099 STOCKTON,CA 95201 <br />