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r _ . <br /> Applications Will Be Processed When Submitted ProperlyCompleted. <br /> APPLICATION <br /> ed <br /> ✓cP <br /> ed /® VO4P (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq In Local Health District.l <br /> r l�fAO� 19 {¢�, , City/Town <br /> Exact Site Address_ � <br /> Phone <br /> Owner's Name • <br /> Address <br /> Contractor's Name LA,.- License# Business Phone <br /> Contractors AddressAF <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes 5e No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION C1 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2f PUMP REPAIR❑ ii <br /> e REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C-6 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> C1 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> a DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t ❑ DOMESTIC/PUBLIC 1:1DRIVEN Gauge of Casing <br /> " ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> s <br /> 13 GEOPHYSICAL Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. S� <br /> PUMP REPLACEMENT: State Work Done 6' <br /> k PUMP REPAIR: ❑ State Work Done <br /> Wel! Diameter Approximate Depth <br /> DESTRUCTION OF WELL: - — <br /> Describe Material and Procedure <br /> t:. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County II <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 /> 1 w"II call for a Grout Inspectio rior rout'n and <br /> d final inspection. <br /> l Signed a itle: ?_,e: � y.. Date: <br /> (Draw Plot Ian on Reverse Side) <br /> "FOR DEPARTMENT USE ONLY <br /> �J <br /> PHASE Ite <br /> ,— <br /> Da0 ` <br /> W�,� <br /> � Application Accepted By i <br /> j Additional Comments: <br /> Phase 11 Grout Inspection Ph a !1t in nspection f <br /> Inspection By Date Inspection By Date 6o y <br /> OF OL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By J nuary 31 ❑ July 1 &Receive y July 3t <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I! <br /> OTHER <br /> 'i <br /> OTHER <br /> Date Receipt No- ermit No. Issuance ate Mailed Delivered <br /> Received by 4 <br /> i. <br /> APPUGANT=flETVRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERYIGHS �1601 E.Hp.ZELTON AVE.,P.O.Box 2U09 STOCKTON,CA 952U14� <br />