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r' -ineApplication. <br /> Applications Will Be Processed When Submitted Properly Completed. BeSureToSign <br /> FOR OFFICE USE: APPLICATION <br /> �i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL ` <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) Local Health District for permit to constru_ <br /> ct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Jo quip ocal Health District. i <br /> 4's C-Azzld� <br /> Exact Site Address } l City/Town <br /> 01 5 <br /> Owner's Name to 3 Phone <br /> Address r f City <br /> - License <br /> Contractor's Name <br /> Business Phone-9v7" ��y <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHO? Yes No h„ <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Oj <br /> REPLACEMENT❑ 1 1 <br /> DISTANCE TO NEAREST: Septic Tank 5 fi Sewer L'+nes Pit Privy <br /> .� — <br /> Sewage Disposal Figld Cesspool/S?epage Pit Other <br /> Property LiII 0f private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE.OF WELL + <br /> ❑ INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation �I <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. a Well Casing <br /> DOMESTIC/PUBLIC E3 DRIVEN Gauge of Casing C <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ROTARY Type of Grout Ar <br /> l ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ob <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I' Approximate Depth <br /> l DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> k 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 forwhich 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:'9 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ pe ons subject to workman's compensation laws of California." <br /> 1 all f r a ou pec nhrlor to grouting and a final inspection. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse de) <br /> F Dat DEP RTMENT U ONLY <br /> PHASE 1 , p <br /> j � �s' o 0 <br /> Application Accepted By <br /> Additional Comments ` <br /> ase I Grout Inspection Phase IN Final inspection <br /> Inspection <br /> ) Date Inspection By Date <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PE, PERPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> p II BILLING REMITTANCE <br /> ! LNATION AMOUNT DUE CHECKED <br /> BASE EXP <br /> DATE DATE REMITTED AMOUNT <br /> FEE fr <br /> LESS <br /> PRORATION_ <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. Issuance Date <br /> APPLICANT—RETURN ALL COPIES TO: I-ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.H. LTON AVE.,P.O.Bow 2009 STOCKTON,CA 95 - <br /> �_ <br />