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Applications Will Be Processed When Submitted Properly Completed. Be ftp To Sign The Application. <br /> FOR OFFICE USE: APPLICATION - --�' <br /> c. <br /> (For Non-Transferable, Revocable,Suspendable)� PUMP &WELL r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COTVIPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/orinstallthework herein described.T�application is <br /> made in compliant+ San J in Cuntydin Ge 1862 an u nd re ulationf� Joan�talh ttar <br /> Exact Site Address �{ GTy/Town �s�� <br /> Owner's Name Phone <br /> t 0 P �t <br /> Address _ _ City <br /> Contractor's Name License# Business Phone <br /> ` 1 <br /> Contractor's Address Emergency Phor}e _ O <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No <br /> TYPE OF WORK (CHECK): NEW WELLVt DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ' WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION e 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 Wel! Q q <br /> INTENDED USE ,i TYPE OF WELL <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 PACKDepth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL r'_ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ~~ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ® t <br /> Type of Pump - <br /> r H.P." <br /> PUMP REPLACEMENT: " �j State Work Done <br /> PUMP REPAIR: ❑4State 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health district. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit <br /> is issued, l 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 for which this { <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> call f a Grout In p on prior groutin land a final inspection. € <br /> Signed X Title: <br /> — r1 ZIOL/Date: <br /> f ; (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I R ; <br /> Date <br /> Application Accepted By <br /> Additional Comments: i <br /> Phase 11 Grout Inspection Phase Ill Final Inspection " <br /> Inspection.By Date Inspe tion By ' <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received ik <br /> By January 31 ❑ July 1 &R y July 3 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �r1 <br /> i <br /> FEE ��. -m r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is ante ate Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601_E.HAZELTON AVE.,P.O-,Bax 2009 STOCKTON,CA 952o1 <br />