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Applications Will Be Processed When Submitted Properly Completed. taebure io sign inexppncaiw ,U; 9�4 <br /> FOR oFFI USE: APPLICATION p <br /> (For Non-Transferable, Revocable, Suspendable) • <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is IN <br /> herRI LICATmadetthe SanJaaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis ` <br /> made in compliance with S n Joaquin Cc ty Ordinance No. 1862 and the rules and regulations of the San Joaqu' Local Health District. <br /> Exact Site Address fL �� <br /> City/Town <br /> 5 'r Phone <br /> Owner's Name p <br /> Address City / <br /> Contractor's Name License Business Phone's <br /> Emergency Phone <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1$ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION t9 PUMP REPAIR❑ ` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank l�b 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 txcaGEfion <br /> 0 DOMESTIC/PRIVATE -E-D Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0-IRRIGATION , �% GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION Ya ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL StIrface-Seal-installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. - A <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 /> Home 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 /> 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 /> 1 ill call for a Grout VIAPection prior tg grou'ng and a final inspection. <br /> Signed X <br /> Title: � Date: J <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPA MENT USE ONLY <br /> PHASE I �C 79 <br /> Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout Inspection Phase III 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 &Receiv <br /> REMITd By 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> S <br /> 00 <br /> 7 n 9 - a 7 <br /> Received by Date Receipt No. Permit No. Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .� <br />