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ppncauonsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> =--- <br /> f <br /> APPLICATION(For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL(COMPLIN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described,This application is <br /> Exact Site Address <br /> made in compliance wit�h San Joaquin Count Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> -� �~ <br /> City/Town <br /> Owner's Name <br /> Address Phone it <br /> Contractor's Name ['L y City (2C j <br /> G � License ! G Business Phone <br /> Contractor's Address t1.� _ <br /> X/ <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLr <br /> HD? Yes �^ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El _.RECONDITIONo I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ P INSTALLATION ❑© <br /> REPLACEMENT❑ PUMP REPAIR❑ (\ ; <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ INDUSTRIALTYPE OF WELL <br /> ❑ <br /> DOMESTIC/PRIVATE CABLE TOOL Dia. of Well Excavation <br /> CABLE <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION ❑ GRAVEL PACK <br /> C] CATHODIC PROTECTION 11Depth of Grout Seal <br /> ROTARY <br /> 11DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> , <br /> Homeowner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit <br /> is issued, I shall not employ an � # <br /> p y y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shalt employ persons subject to workman's compensation laws of California." <br /> ! Il fora Grout Inspe n prior to grouting and a final in <br /> Signed X <br /> e <br /> Title: Date: /TG�o <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ` <br /> ASEI <br /> A PI,c <br /> Application Accepted By <br /> FAdditM, <br /> ional Comments: I Date 1 <br /> Pha a ii Grout Inspection 4 <br /> Inspection By� Phase 111 Final Inspection , <br /> Date Inspection By Date ! l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER uNI El PER SITE EACH <br /> ❑ January i &Received 8y January 31 ❑ July 1 &Received By July 31 <br /> BASE ExPL,NATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE % t AMOUNT <br /> LESS 4 <br /> PRORATION 7 <br /> PLUS k <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by pate # <br /> Receipt No. Permit No. fssuanc Da e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES Maifed Delivered <br /> _ — 164)1 E.HAZELTON AVE.,P.O..Box 2009 STOCKTON.CA 95201 <br />