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Applications Will Be Processed When Submitted Properly Completed Be SureTosign ineAppueanvn. <br /> APPLICATION <br /> FOR OFFICE use: ` <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> llh <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count. Or inan a No. 1862 and the rules and regulations of the San inaf Health District. <br /> z�' City/Town <br /> Exact Site Address g � <br /> Phone <br /> Owner's Name <br /> Address City <br /> Contractor's Name License# Business, <br /> usiness Phone <br /> Contractor's Address 40a r, Emergency Phone I . <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X_._ No W <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN J9 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ a <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy j <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 Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �- <br /> k PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 certify that in the performanceof 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 /> I ' <br /> I w call for a Grout Inspection prior to grouting and a final inspection. �d <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I C Ady I T U <br /> Date <br /> Application Accepted By— -- <br /> Additional Comments: <br /> Phase It Grout Inspection has I Inspection // y <br /> Inspection By Date Inspection By a ( �C� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑.EACH ❑ January i &Received By January 31 ❑ July i &R eived B July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE �[ �3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ` OTHER <br /> t <br /> Received by Date Receipt No. Permit No. !ss nce ate Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />