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--Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ..3 <br /> FOR OFFICE USE: w APPLICATION <br /> w_ (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL 4 <br /> b ENVIRONMENTAL HEALTH PERMIT OQ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is { <br /> made in compliance with San Joaquin ounty Ordinance No. 18 2 and Pe rule and r gut tions n Joaqui Local Health D��i��stff ict. <br /> Exact Site Address� <br /> ylI City/ /1Jr Ag �11.A75 ,!5z p� <br /> Owner's Name Q Phone — <br /> Address City • �� <br /> Contractor's Name License# ,M . Business Phone <br /> Contractor's Address Emergency Phone _062 74 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ � 1 <br /> DISTANCE TO NEAREST: Septic Tank / Sewer tines Pit Privy <br /> Sewage Disposal Field_ Cesspool/Seepage Pito Other <br /> Property Line Private Domestic Well Public Domestic Well l <br /> INTENDED USE TYPE OF WELL <br /> ❑/ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i, aIle <br /> lal DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION K ROTARY Type of Grout <br /> ❑ DISPOSAL ❑I OTHER Other--Information Gt6" <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑� State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth /f <br /> Describe Material and Procedure f <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 /> Homeowner 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 /> 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 /> I wit ca11 for a Grout lnsp 1' n prior to gro sing a sinal ins con. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse S' <br /> FOR EPARTM T USE ONLY <br /> a <br /> PHASE <br /> Application Accepted By °"" Date <br /> Additional Comments: <br /> se 11 rout Inspection Phase Final 1 ection 1 <br /> Inspection By ) Date t'19 7' Inspection By Date i3 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July t &Received By July 31 + <br /> `# BILLING REMITTANCE 5 REMlT <br /> EASE E;PLANATION AMOUNT DUE CHECKED <br /> f DATE DATE REMITTED �rAMOUNT <br /> 2 I <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> 79 Of I 'I - - 7� 4 <br /> Received by Date Issuance Date Mailed Delivered <br />�'` APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES.!' 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON, <br />