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Applications Will Be Processed When Submitted Properly Completed. Be sureTosign 1nerappncauv,r. <br /> FOR OFFICE USE: APPLICATION `y <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL � <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> WATER QUALITY , <br /> (COMPLETE IN TRIPLICATE) application licationls <br /> Application is hereby made to the San Joaquin Local Health <br /> made in compliance with San Joa Lim County Ordinance No. 186 athe rules nd regu tl Cis of the <br /> City/Town Jo in Loc e th Distf <br /> Exact Site Address ! <br /> Phone — F <br /> Owner's Name <br /> g- City <br /> Address <br /> Licensex Business one <br /> Contractor's Name ' <br /> Contractor's Address Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJL Yes <br /> TYPE OF WORK (CHECK): NEW WELL RECONDITION DESTRUCTION <br /> ❑ <br /> D D1:1El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑`i PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ® Sewer Lines <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> I <br /> INTENDED USE TYPE OF WELL �f <br /> i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> s ®DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing / { <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> r <br /> LJ 1❑ CATHODIC PROTECTION 1L11 ARY Type of Grout �- <br /> t ❑ OTHER <br /> 13 DISPOSAL Other Information <br /> ❑ GEOPHYSICAL <br /> rface Seal Installed I <br /> PUMP INSTALLATION: Contractor 4 <br /> H.P. <br /> Type of Pump <br /> - PUMP REPLACEMENT: <br /> ❑ State Work Done { <br /> j PUMP REPAIR: ❑ State Work Done .•P; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F „y <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 for which 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 for which this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." « <br /> I will ca or a_Gr Inspection prior to grouting and fi I inspection. <br /> Title: f Date: <br /> I Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY /, <br /> ' PHASE I f e.0. V Date 7 <br /> Application Accepted By ' <br /> Additional Comments: <br /> Phase 11 Grout Insppiction, as I Final Inspection <br /> c� Date <br /> Inspection By ate 2 V Inspection By <br /> �A* <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JuVy 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �� <br /> Q C? <br /> FEE �� Cr _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - Received by <br /> Date Receipt No. Permit No. Issuance Daie Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />