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Applications Will Be Processed When SubmittedProperly L;omplerea. Desure IV 0+yrl rIra..NNS•.a.•..••- <br /> ^FOR'OFFICE USE:;, APPLICATION <br /> r <br /> - (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> .(COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> Appkication 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 San Joagluin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> � + <br /> Owner's Name Phone <br /> City .- <br /> Address r�r <br /> fLicense# Business Phone� �? <br /> I Contractor's Name <br />` Contractor's Address b Emergency Phone <br /> v �. <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No — <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Cesspool/Seepage Pit Other <br /> Sew <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> `) INTENDED USE TYPE OF WELL <br /> r ❑ 1N STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> !<d'"DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I ❑ 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 i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j ❑ State Work Done <br /> PUMP REPAIR: I! ❑ State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I� Describe Material and Procedure <br /> i- <br /> I� <br /> I hereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. [+ <br /> i Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 'C <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 ship II employ persons subject to workman's compensation laws of California." <br /> I <br /> I will ca f a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: Date: <br /> I (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> 4 PHASE 1 i • 3//.S/Rt� <br /> F Application Accepted By Date <br /> Additional Comments: <br /> + <br /> Phase 11 Grout Inspection t �� Phas 111 F' al Inspection <br /> Inspection By <br /> .1M Date Inspection 8 Date Z <br /> Fee Is Due: ElANNUALLYI�' ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMITd By uly 31 <br /> IN BILLING REMITTANCE $ AMOUNT DUE CHECKED- <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> t PRORATION _ - <br /> c PLUS <br /> PENALTY <br /> OTHER II <br /> L hh�j <br /> OTHER <br /> 0 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed ered <br /> APPLICANT—RETURN ALL OPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> I <br />