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ApplicationsWillBeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> FOR OFFICE USE: APPLICATION 9,j <br /> evil, O 0 (For Non-Transferable, Revocable, Suspendable) I <br /> 1 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> W <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_Z <br /> made in compliance with San Joaquin County Ordinanqg.No. 186 and the rules and regulations of the San Joaquin oc afth District. <br /> Exact Site Address <br /> . City/Town <br /> Owner's Name Phone <br /> Address, City s/ <br /> Contract or''s Name License#10—714� Business Phone Y ? <br /> Contractor's Address o1 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes X _ 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 Pit Other <br /> Property Line Private Domestic Welt Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Welt Excavation <br /> P 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 t� <br /> ❑ GEOPHYSICAL / Surface Seal Instated By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f A H.P. 1 Q <br /> PUMP REPLACEMENT: State Work Done 'N <br /> PUMP+WP7RIH: ❑ State Work Done n <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> I 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 <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 iiiiiii call for a Grout Inspection ri t ing and a final inspection. <br /> Signed X file: date: 7 <br /> (Draw Plot Ian on Reverse Side) <br /> FOR EPARTMENT USE ONLY R <br /> PHASE I <br /> Application Accepted By 2 7 -7f <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill 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 ❑ Juiy 1 &Received By Jufy 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER L' <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />