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l(i�• l <br /> ApiYclltlons Will Be Processed �Jlubmltted Properly Completed.Be sure To sign Ine r<►ppncauvn. <br /> FOR OFFICE USE: q i l L APPLICATION <br /> (For Non-Transferable,Revocable,Su3pendable) PUMP&WELL <br /> VIM .0AQU?N W-VI40NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> HEALTH TH DISTRICT WATER QUALITY <br /> ' '" ���-• ' � ' <br /> Application is hereby madexgj, tgjJoaquin Local Health District for a permit to construct and/or install the work,herein described.This application is <br /> made in compliance with a J n ounty din Ce No.1862 and th ru }} egg lations of the San Paquin ocal Health D' tr c,F� <br /> Exact Site Address I City/Town <br /> � �Phone <br /> Ill <br /> Owner's Name <br /> City_ <br /> Address— - �^r <br /> Contractor's Name ? License# Business Phone_ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION 114. DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMPIINSTALLATION❑ PUMP REPAIR❑ <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 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL. Dia.of Well Excavation <br /> '.DOMESTIC/PRIVATE ❑ DRILLED •- Dia.of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN a Gauge of;Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of,Grout Seal <br /> ❑ <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> - .Surface Seal Installed By: <br /> E j ❑ GEOPHYSICAL _. <br /> PUMP INSTALLATION: Contractor <br /> Typ Pump_ `' H.P. <br /> PUMP REPLACEMENT State Work Done_ _ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -� <br /> Describe Material and Procedure a <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 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 forwhich this <br /> t permit is iss d, I shall employ persons subject to workman's compensatiori laws of California." <br /> will ca or a Grout Inspection prior to grouting an,d a final inspection. 6. <br /> Signed X Date: <br /> ._ <br /> (Draw Plot a Reverse Side) <br /> FOR DEPARTMENT USEONLY <br /> PHASE 1 `v <br /> Application Accepted By Date <br /> Additional Comments: <br /> ' Phase 11 Grout Inspection <br /> Phase III Final Inspection / Z <br /> Inspection By Ny QIP Date :. Inspection By � 4K Date <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT EI PER E <br /> PER SITE ACH' ❑ January 1 S Received By January 31 E] July 1&Received By July 31 <br /> ' REMIT <br /> BASE EXPLANATION <BIL'LING a` REMITTANCE -$ r'" -AMOUNT DUE <br /> ` REMITTED CHECKER <br /> DATE DATEAMOUNT <br /> FEE <br /> LESS �I <br /> 11 <br /> PRORATION <br /> PLUS f - <br /> PENALTY <br /> OTHER yt <br /> OTHER <br /> Received by Date•— Receipt No.- Permit No. ,;y - Is ance ate Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITiSERVICES l 1601 E.HAZELTON AVE..P.O.1}o■20M STOCKTON,CA 95201 <br />