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A I ti ill�'Be0rocessedW ubmitted Properly Completed. Be Sure To Sign The Application. <br /> I FOR OFFICE USE: _ t APPLICATION <br /> t � ' o 119gr Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELt <br /> ,WNMENTAL HEALTH PERMIT <br /> SAN JC)AQk <br /> (COMPLETE-IN TRIPLICATE) u�ALT} DISTRICT WATER QUALITY <br /> Application is hereby madeto the 6�trtJoaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wlt aJ a Co t Ordinagce No. 1862 an ithq rules and regulations of the San oagw'n.LJoc,.�a ealt District. <br /> Exact Site Address �� q <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name UM� License# Bu�sine+ss,Phone 1 <br /> Contractor's Address '� s Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes G____ No x <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION LzY PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well . <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑`DRILLEDDia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC —11 DRIVEN Gauge of Casing � <br /> 11IRRIGATION 11GRAVEL PACK Depth of Grout Seal f <br /> t <br /> ElCATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ru—r- <br /> Pce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Done ,t <br /> PUMP REPAIR: �State Work Done <br /> DESTRUCTION OF WELL: 1Nell Diameter Approximate Depth f <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. :�.J_ <br /> Homeowner 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." rb i <br /> Contractor's hiring or sub-contracting signature certifies the following:' ertify that in the performance of the work for which this IC4 <br /> perm d, I shall empl p sons subject to workman's comp tion laws of California." p <br /> I ill c Lit Inspec 'on p for to grouts g and a sinal ' i n. f <br /> Signed X Date. 11 <br /> Title• _ <br /> (Draw Plot Plan Reverse Side) <br /> t vv R, F R DEPA TMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Q Date <br /> Additional Comments: <br /> Phase If Grout Inspection PhajW It' al Insoectlon --/ <br /> Date Inspection By Date <br /> Inspection By I� <br /> Fee is Due: El ANNUALLY El PER UNIT ic7 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Suly 31 <br /> REMIT <br /> ;BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> e �ti <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r . <br /> OTHER I <br /> _ - F <br /> Received by `- "' Date Receipt No. Permil No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH—PP%-di".;SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> _ y <br />