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._: <br /> -- T Applications Will Be Processed When Submitted ProperlyCompleted. x l • :��. <br /> APPLICATION <br /> FORv0FFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> in Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> Application is hereby made to theSan Joaqu <br /> made in compliance with San Joaquin County Ordinance)Na 1862 and the rules and regulations of the San J aquin Local Health District.. <br /> 4unL�, <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name City c` I <br /> v <br /> Address66 <br /> License# Business Phone <br /> Contractor's Name <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO !^ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> r WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST. Septic Tank <br /> Sewer Lines Pit Privy � - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE —D4 of WeiI'Excavation <br /> X,❑CABLE TOOL <br /> a <br /> 0-INDUSTRIAL Dia. of Well Casing <br /> u DOMESTIC/PRIVATE '❑.DRILLED <br /> I Gauge of Casing <br /> 11 DOMESTIC/PUBLIC. 1:1 DRIVEN YGrout <br /> Seal <br /> l� IRRIGATION 11 GRAVEL PACK Depth of Groout <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> F ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: 11 tate Work Done - <br /> PUMP REPAIR: v state Work Done <br /> - Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter _ <br /> k Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in acc&dahce with San Joaquin County <br /> 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 /> I is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> C 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 /> I will call for a Grout Inspection prior to grow ng and a final inspection. (� <br /> c. '–!tie: <br /> Signed X Date- <br /> J9 <br /> --(DrawPlot Plan on Reverse Side) <br /> FOR DEPART NT USE ONLY <br /> PHASE !, Date <br /> I Application Accepted By <br /> Additional Comments: <br /> Phase III Final ins ection <br /> Phase If Grout Inspection Date /��'� � <br /> Inspection By Date Inspection By - 4 <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 $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DAT DATE REMITTED AMOUNT <br /> FEE <br /> t1 LESS i <br /> ` PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r. <br /> OTHER <br /> r <br /> Receipt No, Permit No. Issuance Date Mailed Delivered <br /> L Received by Date <br /> 1601 E.�HAZELTON AVE.,P.O.Box,2004• STOCKTON,CA 95201 <br /> �:--: APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ r• ', --� - <br />