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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TneAppucanon. _ <br /> _E SE: <br /> APPLICATION <br /> -• ; ,,-• _ (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> fo�25,/ ENVIRONMENTAL EALTH PERMIT 7 <br /> E (COMPLETE IN TRI I <br /> 4'0 <br /> AT <br /> Applicationisherebymadet the San Joaquin Local ealthDistrict rapermlttocons and/or install the work herein described.Thi p cation is <br /> ' made in compliance with Sean Joaquin County Ordinance <br /> � <br /> No. 1-8—62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ fir, City/Town <br /> Phone 6— ® fiZ Z <br /> R Owner's Name <br /> I Address City r <br /> 5k� Li <br /> Contractor's Name cense#.���—1 Business Phone <br /> � <br /> Contractor's Address d Emergency Phone <br /> E OZ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ,Q <br /> s TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[— <br /> WELL CHLORINATION 1111 , <br /> WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION � PUMP REPAIR <br /> REPLACEMENT❑ <br /> t DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IN TRIAL ❑ 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 c' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor rt \ <br /> ` Type of Pump H.P. <br /> F PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> f Describe Material and Procedure <br /> II 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 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 certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout Inspe ion prior to grouting and a final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I ��� <br /> Application Accepted By.� 2-:��� � Date <br /> Additional Comments: - <br /> Phase II Grout Inspection hase III F' al Inspection <br /> Inspection By Date Inspection By ate — <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SkTE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &ReceivedREMITuly 31 <br /> - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE R TED .AMOUNT <br /> t <br /> FEE <br /> LESS <br /> PRORATION <br /> j PLUS <br /> 6 PENALTY <br /> OTHER <br /> lOTHER <br /> �S 1: -/,5-- <br /> Received by- Date Receipt No. Permit No.� IssLiance Dat Mailed Delivered <br /> 1, <br /> 11301 E.HAZELTON AVE,,P.O.Boa 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITlSERVICES <br />