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ppuearronswillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign Th Ae ppfication, <br /> I <br /> [FOR OFFICE USE; <br /> APPLICATION . / <br /> t R <br /> (For Non-Transferable, Revocable, Suspendable) !/ <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE <br /> WATER QUALITY <br /> Appl ication 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 S J aquin ounIt�y�Ordin ce No. 1862 an rut s and regulations of the San J uin Local Health District. <br /> I Exact Site Address +�I% <br /> i City/Town ^tL� <br /> I Owner's Name ti .. �� <br /> Address Phone <br /> i�l6 City <br /> Contractor's Name i. 06 License# 3 L � Business Phone__r <br /> Contractor's Address C7 0 <br /> Emergency Phone <br /> i Is Certificate of Workman's Compensation !n urance on File With SJLHDI Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION❑ No <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMPDESTRUCTION❑ p� <br /> INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 f <br /> DISTANCE TO NEAREST: Septic Tank �'(/ <br /> p � Sewer Lines fyf Pit Privy <br /> Sewage Disposal Field p <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia, of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC ElDia. of Well Casing <br /> DRIVEN Gauge of Casing �[ <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION %-OTARY Type of Grout R •- <br /> ❑ DISPOSAL OTHER El GEOPHYSICAL Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that 1 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, ! 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 for which this <br /> Permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout In pection prior to grouting and a final inspection. <br /> Signed X. Title: <br /> ?!NDate: 3 j <br /> (Draw Plot Plan on Reverse Side) 1 <br /> r <br /> # <br /> PHASEI FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> e out Ifispectia �/ Phas Il 'not I <br /> Inspection By Date pection <br /> Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 5 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATEDATE REMITTED AMOUNT DUE CHECKED - <br /> -FEE - <br /> AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS } <br /> PENALTY t t <br /> OTHER <br /> i <br /> OTHER / <br /> Received Date Receipt No. Permit No <br /> Iss once ate Mailed Delivered <br /> APPLIC NT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE:,P.O"9ox 2009 _ sTOCKTON,CA 95201 � <br />