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plications Will Be Processe�ll'�l�en Submitted Properly Completed. Be Sure To Sign The Appllcation. t <br /> FOR OFFICE US JUL q gnOq J APPLICATION <br /> U J IJU I <br /> For Non-Transferable, Revocable, Suspendable) irz <br /> PUMP&WELL i <br /> AN J-0,'' aUIN LOCFbVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLWA+J) LTA DISTRICT WATER QUALITY + <br /> Application is hereby made to the San iJoaquin Local Health Districtfora permit to construct and/or install the work, in described.This application is <br /> made in compliance with Joaqui rntY'3Wynce No. 1862 a t e rule and regulations of the San J u' t_ <br /> Exact Site Addre /J City/Town <br /> Owner's Nam Phane <br /> Address ` ' <br /> 1 ty. <br /> Contractor's Name Lic s # sin Phone <br /> Contractor's Address ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK: NEW!WELL 11DEEPEN E] RECONDITION ElDESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR } <br /> REPLACEMENT❑ A <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 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 1 ❑ ROTARY Type of Grout d <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor € <br /> Type of Pump H_P 4 <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> o <br /> PUMP REPAIR: 01'State Work Don <br /> DESTRUCTION OF WELL: Wel! Diameter Approximate Depth 9 <br /> Describe Material and Procedure <br /> I C4 <br /> 1 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, aA rules and regulations of the San Joaquin Local Health District. �`x <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance o€the work forwhich this permit 1 <br /> is issued, I shall not a loy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contract s 1 ' r sub contractin ture certifies the following:"I certi t in the performance of the work for which this <br /> permit sue shall hploy p sons su ject to workman's compensati n ws of California." s <br /> E <br /> I wil c 1 e t' or to o ,final inspection. <br /> Signed X �� = Title: Date: <br /> 1 (Draw Plot Plan on R erse Side) <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> y <br /> Phase R,Grout Inspection Pas III Fi at Inspection <br /> Inspection By Date Inspection By `U Date 16r�� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recsivbd By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> .BASE. EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> yI { ! AMOUNT <br /> q <br /> FEE <br /> LESS 1I <br /> PRORATION <br /> PLUS gry <br /> PENALTY <br /> OTHER <br /> OTHER. <br /> Received by-. Date ill: Receipt No. Permit No. ssua a Date Mailed Delivered <br /> w APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P,O,Box 2009 STOCKTON,CA 95201 <br />