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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplicatin. <br /> FOR OFFICE USE: APPLICATION 13 <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <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 is <br /> made in compliance wit San Joaqui C unty Ordinance No. 862 an the r s and egulatior,s of the San Joaquin Local Health District. <br /> Exact Site Address ^� K City/Town <br /> Owner's Name Phone <br /> Address ame City <br /> Contractor's NLicense Business Phone <br /> Contractor's Address 4 611 <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance==D?With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑' DESTRUCTION❑ x <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION /PUMP REPAIR❑ J <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 Well Public Domestic Well <br /> INTENDED USE a TYPE OF WELL. <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/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 r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� ��9— � <br /> Type of Pump H•P.__ G <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> �1I <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 ofthe 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 ,e <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi Grout Inspection for to grouting and a final inspection. I _ <br /> Signed X Title: Date: l <br /> (Draw Plot Plan on Reverse Side) <br /> L FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> Application Accepted By ' ���' Date S� <br /> Additional Comments: <br /> Phase IlAdo t-.inspection �' Ph se II Final Inspectio <br /> Inspection By b E � Date ' Inspection By Date <br /> >s <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />