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_ <br /> Applications Will Be Processed When Submitted ProperlyCompleteCl. tie *ure ivalull 1 _ <br /> APPLICATION <br /> FOR OFFICE USE: <br /> F <br /> (For Non-Transferable, Revocable, SuspendabYe) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 4 + <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District forapermittoconstructand!orinstallthework.hereindescribed.Thisapplicationi's <br /> Application is <br /> made in compliance with San Joaquin Count Ordinance No. 16fi2 and the rules and regulations of the San Joa uin Local He <br /> 1862 <br /> City/Town d : <br /> Exact Site Address <br /> Phone <br /> Owner's Name City <br /> Address f <br /> License# Business Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address r� No } <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> NEW <br /> DEEPEN ❑ O❑ ITIO UO DESTRUCTION <br /> TYPE OF WORK (CHEMP INSTALLATION 13 PUMP REPAIR <br /> WELL CHLORINATIONWAB ABANDONMENT ❑ OTHER <br /> 1 <br /> REPLACEMENT❑ r <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST. Septic Tank Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line{ Private Domestic Well Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> �� <br /> 13 INDUSTRIAL CAB_LE TOOL pia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> IGfDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> C1 DISPOSAL 13 OTHER Other Information 6. <br /> Surface Seal Installed By: K <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 tollowirig:"I certify that in the workman's <br /> performanceofthe work for which this permit 44 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."i <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 /> P I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: ; <br /> Signed X <br /> (Draw Plot Plan on Reverse Side <br /> FO DEP TMENT USE ONLY f <br /> r PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase ill Final Inspection <br /> inspection By <br /> Phase II Grout Inspection Date <br /> Date Inspection By <br /> t <br /> Fee IS Due: ❑ ANNUALLY E] PER UNIT VIPER SITE ❑ EACH C3 January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> + ( BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> ! FEE It ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L <br /> C OTHER <br /> L OTHER a <br /> �. <br /> R <br /> Issuance Date Mailed Delivered <br /> Date Receipt Nv.. Permit No. <br /> Received by� Da1601 E.HAZELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br /> ' APPLICANT—RETURN ALL COPIES TO:.t ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />