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I• Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> r (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in complianceTY <br /> an Joaquin county,Ca rdinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address w _�jv p A. City/Town <br /> ! Owner's N me #NiZA 't -, Phone 16C <br /> " Address <br /> City <br /> Contractor's Name 11611 License#W74 Business Phone_�f <br /> Contractor's Address Na Emergency Phone &4/0� <br /> Is Certificate of Workman's Compensation lnsur nce on File ith SJLHD? Yes 4 No <br /> ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT M— <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines� – Pit Privy <br /> Sewage Disposal Field &q2 Cesspool/Seepage Pit Other <br /> Property Line 13 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation w <br /> &;^SQMESTIC/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 /> l ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rvz Al H P <br /> PUMP REPLACEMENT: State Work Done_/a!!?!( <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certifythat 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I will call for a Gr t nspection prior to grouting and a final inse epectio <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Rrse Side) <br /> 7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By b <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection se III Final Inspection C <br /> Inspection By %(\N Ql� Date Inspection By ate ' �U <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By*uary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No Iss ance ate Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2009 STOCKTON,CA 95201 <br /> r - <br />