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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> FOR o FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> C <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862d the rules and regulations of the San quin Loc I Health District. <br /> Exact Site Address `t ` I VN City/Town �j <br /> Owner's N me - - G Phone 6 "`q <br /> Address ��• "" '� City <br /> Contractor's Name r>t;, License#'-`'f r Business Phone <br /> Contractor's Address `I"' * ' Emergency Phoney _ ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _- O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 p Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑'DRILLED I Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC {k 11DRIVEN �,, Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY j11 T <br /> _ ype of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL, 7� '., �° Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ H.P. (� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REP ❑ State Work Done _ <br /> DESTRUCTION OF WELL: r Well Diameter rr . Approximate Depth ` <br /> Describe Material and Procedure - <br /> 1 hereby certify that,I have pre tired this application and:that the wor -will be done in ccordance with San Joaquin C unty. _ <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 following:"I certify that in the performance ofthe work forwhich 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 I <br /> permit is issued,'I'shall employ persons subject to workman's compensation laws of California." <br /> a <br /> 1 I all f r a G{ut Inspect!g 1-0or 011routing and -final inspection. 3 <br /> Signed X Title: Date: <br /> f (Draw Plot Plan on Reverse Side) <br /> . *r <br /> - FOR DEPARTMENT USE ONLY <br /> PHASEI 3 <br /> a <br /> Application Ac(,epte y f Date f <br /> Additional Comment42 <br /> Phase II Grout lnspection� �" Phase III Final Inspection <br /> Inspection By Date - Inspection'By _ Date <br /> Fee Is Due: ❑ ANNUALLY y -[].PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> -BILLING .REMITTANCE . $ <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT ? <br /> fLESSFEE )a V—;-- <br /> LESS <br /> PRORATION <br /> PLUS v _ <br /> PENALTY C d <br /> OTHER 5 1 <br /> OTHER <br /> jos <br /> Received by uate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />