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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFME USE: L APPLICATION <br /> (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALT'H'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ApplmadeinompliaherebymadetokheSanJoaqufrtLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is ; <br /> made in compliance with S n Joaquin Cc my rdin n No. 1862 and the rules and regulations of the San!Joaquin Local Health District. <br /> Exact Site Address Cityhown , T. <br /> Owner's Name I Phone' G. <br /> Address r <br /> City, <br /> Contractor's Name License#" <br /> B mess Pho e f <br /> Contractor's Address Emer9 4Y <br /> eh Phone i. • 1 _� <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 /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ -J I <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 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC u❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ,❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Iii ri��t 1� 1 <br /> PUMP REPLACEMENT: ❑ to Work Done f Q <br /> PUMP REPAIR: i c <br /> DESTRUCTION OF WELL: Well Diameter Approxima e bepth <br /> Describe Material and'Procedure <br /> I <br /> I hereby certify that I have prepared this applicationland tliat the work will be done in accordance with San Joaquin County <br /> —:1 <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 the work for which this permit <br /> f <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w I call fora Grout I ecli prior to grouting and a final inspection. <br /> k <br /> Signed )( _ Title: Date: <br /> " -- (Draw-Plot Plan on Reverse Side) <br /> .- r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> -' -- - -Phase'II-Grout Inspectfon` ase III Final Inspection <br /> Inspection By �._t.Date— Inspection By- <br /> t •ala Date q--P-a <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 1 ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE_ REMITTED <br /> r AMOUNT <br /> FEE W � { <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER w <br /> OTHER <br /> Received by I Date I Receipt No. Per�. No. - _ 'Issuance Date Mailed .�Deliveyed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009/STOCKTON,CA 95201 <br />