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Applications Will Be i . —ed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 8 (For Non-Transferable, Revocable, Suspendable) <br /> I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I' (COMPLETE IN TRIPLICATE) WATEs 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 an Joaquin County Ordinance No. 1862 and the rules and regulations of the San o quin ocal Health District, <br /> Exact Site Address City/Town <br /> Owner's NamePhone --Z--� <br /> Address - City <br /> Contractor's Name License fly Business Phone <br /> Contractor's Address Ilev Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Ith SJLHD? Yes No j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER ElL <br /> PUMP INSTALLATION R1--"`PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> `9 <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 /> ❑ II USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ET DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN R Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHERS., Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. _ —J <br /> r PUMP REPLACEMENT: ❑ State Work Do <br /> t <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well DiameterA <br /> � pproximate Depth <br /> Describe Material and Procedure U <br />'h I hereby certify that,l 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. l <br /> Home owner or licensed agent's signature certifies the following.'T.certify that in the performance of the work for which this permit <br /> is issued, I shall not employ a`ny person in such manner as-,to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifie's the following:"I certify that in the performance of the work for which this <br /> permit is issued, Itshall employ persons sdbject to workmall's'compensation laws'of California." <br /> r a Grout Inspection prior to grouting and a•.final inspection. <br /> Sign NTitle: c3� Date: Q <br /> _ _ _3_nto 5�'� <br /> (Draw"Plot 'Plan on Reverse Side) <br /> r. FOR DEPARTMENT USE ONLY ti <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III 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 /> REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �1 AMOUNT <br /> FEE 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> b SD? 1*1 <br /> Received by Date Receipt No. Permit No. lisguanbe Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />