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_- ocessed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or i nstal l the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an the rules and regulations of the Sart Joaqin Local Health District. <br /> Exact Site Address r C9C A City/Town <br /> i <br /> Owner's Name 1 e Phone <br /> Address <br /> a" A City— <br /> Address <br /> Contractor's Name 6' <br /> e!. AA f License#��Business Phone �- } <br /> Contractor's Address tr+4 Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran a on File With SJLHD? Yes 11 No �l <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M— PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank to Sewer Lines Pit Privy /t'"��` - s <br /> Sewage Disposal Field 1 5' Cesspool/Seepage Pit 1�'4c A-( Other <br /> Property Line Private Domestic Welt 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 /> ❑160MESTiC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information , S� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ! <br /> PUMP INSTALLATION: Contractor 'wt <br /> Type of Pump ah An=zl? H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State 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 /> Rome owner 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 /> 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 Inspectio - 'or to grouting nd a final tnspectI <br /> Title: Date: <br /> C <br /> Signed X , <br /> (Draw Plot Plan on R verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By w Date <br /> Additional Comments: <br /> t Phase II Grout Inspection ha 111 Final Inspection <br /> Inspection By Date Inspection By Date <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 /> BASE EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AMOUNT <br /> FEE <br /> k <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a3(A <br /> Received by Date Receipt No Permit No. "Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />