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iications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Aplljlio ion. w. u LuAPPLICATION �L <br /> - f� q�1 <br /> _ (For Non-Transferable, Revocable, Suspendable) PUMP&WEr iJ � <br /> I ENVIRONMENTAL HEALTH PERMIT ,% <br /> . SAN JOhQUr1i LOCAL <br /> �4LETS IN TRIPLICATE) WATER QUALITY:.,,, HEALTH DISTRICT ' <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 appiication Is <br /> made in compliance with Sa Joaquin Cou Ordinance No. 1862 an the rules and regulations of the San Joaquin Local ealth District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone moi!'r�LZ7—� <br /> Address G ity. Z <br /> Contractor's Name License# usjpe s Phone <br /> Contractor's Address - Emergency Phone ,CEL <br /> Is Certificate of Workman's mpensation 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❑ <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 /> I TENDE=D USE TYPE OF WELL <br /> IN USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r <br /> ❑ D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IR IGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ ATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ ISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:_-_ - ❑ Std 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 /> 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 for which this <br /> permit is issued, I shall employ persons s ject to orkman's compensation laws of California." <br /> 7I c 1 for a Grout Inspe o prior grouts and a final inspection. <br /> Signed X _ <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> Application Accepted By DateR� ��� <br /> 'Additional Comments: <br /> t Phase II Grout Inspection hase Ili Final Inspection <br /> _ Inspection Sy �� �� Date inspection By Vale ��' �3 <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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> OO <br /> FEE <br /> LESS <br /> PRORATION <br /> 5 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Iss ance Dallp Mailed Delivered <br /> s APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 / <br />