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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> w y� a (t (For Non-Transferable,Revocable,Suspendable)- PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT l <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Joaqui County Ordinance NT. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address go J A b E A & City/Town <br /> Owner's Name Z gL LZ Phone <br /> AddressAl <br /> City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes XNo d , <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11ECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Jff 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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> W DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump k H.P. <br /> PUMP REPLACEMENT: 9 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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 forwhich this <br /> permit is issued, I shall emplo ersons sub' o workman's compensation laws of California.'' <br /> I ill call fora Grout cti n ri to and ' al inspection. t <br /> Signed X13 Date: <br /> o (Draw Plot P n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection abas ill Inspection <br /> Inspection By Date Inspection By C 1�'y Date .� `l -7, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE` ❑ EACH ❑ January I&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE '� c <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C.� <br /> Received by Date Receipt No. Permit No. $suancp 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 />