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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 ti <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 <br />is_ <br />made in compliance wi San Joaq in CountyfOr, i nc No_1862 and the r les and regulations' 'of the San J aquin Local Health District. <br />Exact Site Address' City/Town �y <br />Owner's Name �- Phone r <br />Address City i� T <br />Contractor's Name License #c�'�r%/ Business Phone �� JUS, Contractor's Address mergency Phone ' F <br />Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 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 PrivyI <br />Sewage Disposal Field Cesspool/Seepage Pit Other <br />Property Line Private Domestic Well = Public -Domestic W u, <br />INTENDED USE <br />�❑, IN '�STRIAL <br />f� DOMESTIC/PRIVATE <br />❑ DOMESTIC/PUBLIC <br />❑ IRRIGATION <br />CATHODIC PROTECTION <br />❑ DISPOSAL <br />❑ GEOPHYSICAL <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT:' <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />TYPE OF WELL <br />e <br />❑ CABLE.TOOL ._ <br />_ _,_Dia. of Well Excavation.,. <br />❑ DRILLED <br />Dia. of Well Casing <br />❑ DRIVEN <br />Gauge of Casing <br />❑ GRAVEL PACK <br />Depth of Grout Seal <br />❑ ROTARY <br />Type of Grout <br />❑ OTHER <br />Other Information <br />{ <br />1 Surface Seal Installed By: _ <br />Contractor <br />Type of Pump <br />H P <br />State Work Done <br />❑ State Work Done <br />e Diameter 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 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 of the work forwhich this permit o <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 forwhich this <br />permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />I will o > Grout Inspe prior to grouting and a final inspection. t <br />Sig4�X Title: Date: 8-3 ' <br />(Draw Plot Plan on Reverse Side) <br />FOR DEPARTMENT USE ONLY <br />PHASE I - <br />Application Accepted By—` �- _ Date <br />Additional Comments: # <br />Phase II Grout Inspection r P s I nal Inspec I n �^ �f <br />Inspection By Date . Inspection By Date _ l/ 1 4O <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />BILLING REMITTANCE $ REMIT <br />BASE - EXPLANATION <br />- /` DATE DATE REMITTED AMOUNT DUE CHECKED <br />' r AMOUNT <br />FEE d . C;l <br />LESS <br />PRORATION 1 v <br />PLUS <br />PENALTY <br />OTHER <br />OTHER �) r <br />Recewed by .. Date ;-Receipt Na- _ Permit No. <br />APPLICANT --RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH'PERMITISERVICES <br />I <br />' Issuahce Date Mailed <br />1801 E. HAZELTON AVE., P.O. Box 2009 <br />1 - <br />Delivered <br />STOCKTON, CA 95201 <br />