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A pticatlbnWil- Processed f ubmitted Properly.Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: Sa APPLICATION <br /> {I�1 — "(For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> SAV J0P,QL€N LRMRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATEfflt rtLI H DIST C7 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. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address City/Town <br /> Owner's Name ' Phone '" y <br /> Address <br /> Contractor's Name License# Business Phone L 7zJ s. • <br /> Contractor's Address 4--i ' ±3Emergency Phone, 0 r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 'y 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 Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pio - Other <br /> 'i <br /> Property Line Private Domestic Well Public Domestic Well j <br /> INTENDED USE TYPE OF WELL l <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 17"'Ttld1[ ` .csC� - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter sf, Approximate Depth <br /> Describe Material and.Procedure - <br /> 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 Nles,and-re`g`ulations of the San Joaquin Local Health District. <br /> rk t <br /> Home owner or licensed agent's signature certtifies 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 sup-contracting signature certifies the following: I certify that in the performance of the work forwhich this <br /> permit is issued, l shall employ persons subject.to'workman's compen§atiori laws of California." ; <br /> 1 w114 call for, Grout Inspection prior to grouting and a final inspe on. <br /> Signed X1 •-t Title: Date: <br /> t 1 <br /> (Draw Piot Plan on Reverse Side) <br /> • FOR DEPARTMENT USE ONLY Ar <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection as 1 Ftnal Inspection 3 <br /> Inspection By Date Inspection By Date <br /> 3: , - a <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 /> BILLING REMITTANCE $-BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED i <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS CA QUI.-O, r .'A <br /> PENALTY i <br /> OTHER ����V F^HYh-ff .7 <br /> OTHER <br /> Received by Date Receipt No, - Permit No. - - Iss ance to Mailed —Delivered, <br /> I--:— APPLICANT—RETU R N <br /> Delivered.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />