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�-. ...... <br /> Applications Will Be Processed When Submitted Properly omp <br /> ! z . - APPLICATION 1 <br /> FOR OFFICE-',USE: '� r •` <br /> .ra..� <br /> �! (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY I <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an h rules and regulations of the San Joaquin Local Health District. <br /> f l p- j- City/Town TT <br /> Exact Site Address f—��--���— � <br /> Phone <br /> Owner'sCT- <br /> Name City <br /> Address ;1--7 -- 1 <br /> Contractor's Name <br /> yz' License# Business Phone <br /> Emergency Phone <br /> Contractor's Address No �3 <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ iESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> Tank 5-0 (Sewer Lines y <br /> DISTANCE TO NEAREST: Septic <br /> Cesspool/Seepageposal Field Pit Other <br /> Sewage Dis ~ <br /> Property Line_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL J <br /> ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE 11 DRILLED pia. of Well Casing <br /> l DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing ' <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION �'/ ���. <br /> 11 DISPOSAL ❑ OTHER Other Information�.,fl�? <br /> Surface Seal Installed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 'r <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the pe formanceof the work f rw is Cal fo this n ait . <br /> is issued, I shall not employ any person in such manner as to become subject to workman's coo p <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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will I for a Grou I pection prior to grouting and a final inspection. <br /> Title: Date: r <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) , <br /> ka <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I * oq Dateu- <br /> Application Accepted By l <br /> r Additional Comments:- # <br /> se I1 Grou spection Phase 111 Final Inspection <br /> IInspection By <br /> Inspection By <br /> Date <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ©July 1 &Received By REMITuly 31 <br /> I EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> FEE <br /> � f <br /> LESS B <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ir <br /> ' - :Date Receipt No.. Permit No. - ssua ce Date Malted Delivered . <br /> Received by <br /> _ APPLICANT—RETURN ALL'COPIE5 TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON�AYE.,P.O.Box 2909 STOCKTON,CA 9524 — <br />