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Appl!Wons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f <br /> FOR OFFICE USE: APPLICATION .� <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is t <br /> made in compliance vvi an oquln C unty Ordinance o1862 and the rules and regulations of the San oaquin Local Healt District. <br /> Exact Site Address / 7 ac <br /> aam!y �' IJ City/Town �_<,Cq-Lo <br /> Owner's Name e2,A-L Phone 6o 7 <br /> Address City <br /> Contractor's Name r' w AJ eLicense# Business Phone <br /> Contractor's Address Emergency Phone <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❑ <br /> REPLACEMENT❑ / _ <br /> DISTANCE TO NEAREST: Septic Tank L0 Sewer Lines Pit Privy <br /> Sewage Disposal Field J'f' Cesspool/S epage Pit �3 o Other <br /> Private Domestic Well d \ ublic Domestic Well Al 4 <br /> Property Line <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 ❑ 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 H.P. <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 /> Homeowner or licensed agent's signature certifies the following:"1 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 ill call for yt'llpsp tion rior to grouting and a final inspection. <br /> Signed X (�JI Title: Date: U <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMEN USE ONLY <br /> PHASE I Dat 0 y <br /> Application Accepted By 111 e <br /> Additional Comments: <br /> Phase II Grout Inspection ehase 111 Final Inspection <br /> Inspection By Date Inspection B % Date ✓ " <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT /1� PER SITE ❑ EACH ❑ January 1 &`Epee ived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT/ <br /> FEE S C7 v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C� k.0 a. <br /> \15tmzcf 1 S Z �GT- 1�gii 1V3P/7y <br /> Received by Date —I— Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTONr6Ita9Z01 <br />