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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT % v <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance w_ithSan Joaquin County Ordinance No..1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I City/Town ¢ <br /> Owner's Name <br /> R , , Phone <br /> . ' r <br /> Address _� to-trL� -� a City �GJ <br /> Contractor's Name T License# __ Business Phone '`, 5'L <br /> Contractor's Address �' X30 Y 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❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIO PUMP REPAIR❑ <br /> REPLACEMENT%,-' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -{ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ iN STRIAL - ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/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 V" ' <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 subject to workman's compensation laws of California." <br /> I will Walt r a rout Inspectlon prior to grouting and a final inspection. <br /> Signed X <br /> /.�-v Title: Date: ~� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ".,�'6!� Date <br /> Additional Comments: <br />} <br /> Phase II Grout InspectionP a Final Inspection <br />' Inspection By Date Inspection By Date <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 \r <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt ND. Permit No, Issu nce Date t Mailed Delivered — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />