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ApplicationsWillBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .i,FOR.O,fFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> F, ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Or inance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address A,1 City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name e n s e# ,R 7 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insu5ace on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ti <br /> Sewage Disposal Fiel� �` �1:: Cesspool/Seepage Pit Other .Y <br /> Property Line-1-9A- Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ®� " <br /> ❑ INDUSTRIAL CABLE TOp� Dia. of Well Excavation U <br /> �'�MESTfClPRIVATE ❑ DRILLED - Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN T Gauge of Casing / <br /> ❑ IRRIGATION ❑ GRAVEL PACKr t Depth of Grodt-Seal ZS427`• \ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY # Type of Grout_ , <br /> ❑ DISPOSAL ❑ OTHER ~ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor W <br /> Type of Pump H p <br /> PUMP-REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter. - Approximate Depth <br /> I 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 employ persons subject to workman's compensation laws of California," <br /> I will ca for a Grout In7t17 <br /> uting and a final inspecii <br /> Signed X Title: Date: <br /> (DraPlot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By DatejJ <br /> Additional Comments: <br /> out Inspection Phase III.Final Inspection <br /> Inspection By-X= <br /> e II Gr � <br /> Date Inspection By - , DAA_� Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ 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 AMOUNT <br /> FEE O a <br /> LESS <br /> PRORATION <br /> PLUS y <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _11 d <br /> Received by Date 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 STOCKTON,CA 95201 <br /> _ .J <br />