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Applications Will Be Processed When Submitted Properly Compietea. rse sure 10algn rnehppucatwn. <br /> FOR OFFICE USE: APPLICAT{ON <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 4 <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 Ordinan5p No. 186 and In M <br /> rules an re ations of the San Joa 1 Local Health District. <br /> Exact Site Address C, City/Town e�„ /�� <br /> Owner's Name r�-Q f C4 Phone Y-J 6—C.- <br /> (_I �� <br /> }� City /r4 <br /> Address t. <br /> Contractor's Name Cr! License #J3 Z1 Business Phone ?�- <br /> Contractor's Address 91 a,,e Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L-"- No <br /> TYPE OF WORK (CHECK): NEW WELL 9?'- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ y <br /> REPLACEMENT❑ /,F <br /> DISTANCE TO NEAREST: Septic Tank 10 Q Sewer Lines <br /> Sewage <br /> Pit Privy <br /> Sewage Disposal Field 100 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f ft i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I <br /> ❑ DOMESTIC/PUBLIC ❑ RIVEN Gauge of Casing <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 16 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ori <br /> ' o <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> 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, l <br /> Home owner 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 any person in such manner-as to become subject to workman's compensation laws of California." a <br /> Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work forwhich this a <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout In a on prior to grouting and a final inspection. <br /> Signed XTitle: Date: <br /> ( w Piot Plan on Reverse Side) <br /> f <br /> t <br /> FOQ D PARTM NT USE�OykY <br /> I PHASE l Date#4�4?C:7' <br /> Application Accepted By - <br /> Additional Comments: <br /> P I r mit Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> r OTHER .. - . <br /> l Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA-95201 <br /> W _ <br />