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Applications Will,Be Processed When SubmittedProperlyComplete i s toJs� �ewplxmall i <br /> FOR oFFlcl=USE: APPLICATION 8U �3 <br /> 1. .. - (For Non-Transferable, Revocable, Suspe��+d. e) <br /> OV PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY5l.,.N It„ "� `� <� <br /> f ,� <br /> Application is hereby madetotheSanJoaquin Local Health District for apermit toconstructand/orinstMjWW_&k�hP described.This application is <br /> made in compliance with San Joaquin Cpunty rdi ce No. 18 an the rules and .requlations of the SarlJoaquin Local Health District, <br /> Exact Site Address L11-0 14 2 <br /> ._ City/Town <br /> Owner's Name -IsPhone ' <br /> Address City - <br /> Contractor's.Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> �� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes -� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 1 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lirie: ��Z11' :Pi ri vae�Domestic Well p Pubic Domae <br /> stic Well <br /> INTENDED"USE TYPE-OF <br /> i9 ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> I DOMES TIC/PRIVATE 11 DRILLED Dia. of Well Casing s <br /> L7 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal w J _ <br /> ❑`CATHODIC PROTECTION C1 ROTARY Type of Grout _ -�!j K ,P� 1^• �f y <br /> i ❑DISPOSAL ❑ OTHER Other Information t <br /> 13 G EOPHYSICAL Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor s <br /> is s <br /> �b 4 Type of Pump H.P. ISO <br /> PUMP REPI_AICEMENT: <br /> ❑`State Work Done <br /> PUMP REPAIR: ❑ State Work Done A F <br /> 2' i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application a ib that the work will be done i accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the,Stin Joaquin Local Health District. <br /> f <br /> Home owner or licensed agent's signature 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 or sub-contracting signature certifie06 following:"I certify that in the performance of the work forwhich this <br /> Perm it-ismissued-1>shal kern ploy,persons-subjectAo-workmanis.compensation-laws of.California." <br /> I will all forr as Grout In pectin prior to grQuling and a final inspection. <br /> Signed X �%/ 1� Title: —A 1..- _,�� gl Date: O< <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q1 4 11"�e -CY <br /> Application Accepted By f Date <br /> f *” <br /> Additional Comments: i ' <br /> Ph Grout In ection ,P se II Final In ection 10 Aid <br /> 1 ate Inspection By r Date �� T' <br /> Inspection By <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv8y January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $,t - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> PRORATION <br /> PLUS ! { L <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> Received by Date Receipt No K Permit No. Is uance ate Mailed Delivered- <br /> by <br /> elivered t-.. <br /> _ APPLICANT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 952011 <br />