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Applications Will Be Processed When Submitted ProperlyCompleteO. <br /> FOR OFFICE USE,.,. APPLICATION <br /> For Non-Transferable, Revocable, 1<ele �Pump'&WELL <br /> ENVIRONMENTAL HE RMI�f� 1di� <br /> WATER.QUALI t <br /> (COMPLETE IN TRIPLICATE) a'_ � In described.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtfora permittoco ructan /orinsta <br /> made in compliance with San Joaquin C unty Ordinance No. 1862 and the rules and regulaP s f�L� oaquin Local Health District. <br /> �SD I� n <br /> Exact Site Address E <br /> r Phone <br /> Owner's Name City <br /> Address —110 <br /> Contractor's Name <br /> License#�— Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 11 RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER C] PUMP INSTALLATION❑ PUMP REPAIR <br /> WELL CHLORINATION ❑ ` <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Cesspool Pit Other <br /> Cess <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well <br /> 4 <br /> INTENDED USE TYPE OF WELL - <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ PvMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information O <br /> ❑ GEOPHYSICAL Surface Sea; Installed By: <br /> PUMP INSTALLATION: Contractor -.o I <br /> E Type of Pump H.P. <br /> PUMP REPLACEMENT: 11 tate Work Done <br /> PUMP REPAIR: State Work Don d <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <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 /> Home owner or licensed agent'Iisignature 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall emploipersons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: _ _Date: <br /> -_ (Draw Plot Plan on Reverse Side) <br /> FO DEP RTMENT SE ONLY <br /> PHASE i ® Date <br /> l Application Accepted By <br /> I Additional Comments: <br /> Phase 111 Final Inspection <br /> Phase 11 Grout Inspection <br /> ! D <br /> Inspection By <br /> Date Inspection By ate <br /> k ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Received By January 31 F-1July1 &Received EMITBy uly 31 <br /> Fee IS Due: El ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE-- REMITTED AMOUNT <br /> s <br /> FEE <br /> s LESS <br /> € PRORATION <br /> PLUS <br /> PENALTY 1 f <br /> U1 S-e-a{L �QT I-ed <br /> OTHER <br /> OTHER <br /> nJ /a <br /> Date t Receipt No, Permit No. Issuance Date Mailed Delivered <br /> Received by _ <br /> n APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,C1ir95Z0 <br />