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$- Applications Will Be Processed When Submitted Properly Com Wd.�YureTo Sign The Ap �i anon. <br /> FQR OFFICE USE: APPLICATION � f{�� q p 1979 �...:-s 1 <br /> (For Non-Transferable, Revocable, SuspendAiQIT 1 8 S`I <br /> ENVIRONMENTAL HEALTH PE iT ��{, PUMP&WALL j <br /> iF,.0U11N AL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S HEALTH DISTRICT J <br /> 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with S In Joaquin County Or manceNo 1862 and t rules and regulations of the San J9aquin ocal Health District. <br /> Exact Site Address i City/Town <br /> / — l <br /> Owner's Name l Phone <br /> Address A I City <br /> Contractor's Name r _ (cense Business Phone_ <br /> Contractor's Address Li FS Ill Emergency Phone <br /> Is Certificate of Workman's Compensation Insuranc File With SJLHD? Yes G---- No n� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r' <br /> P WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11i PUMP INSTALLATION PUMP REPAIR❑ C� <br /> REPLACEMENT❑ 1 <br /> 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 /> ❑ INDUSTRIAL ❑ 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 Surface Se I nstf�(led By: <br /> PUMP INSTAL I AT'abi Contractor s �, <br /> Type of Pump c " H.P. <br /> r UMP REPLACEMENT: ❑ State Work Done <br /> PUMP R ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i< <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 <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 lhework forwhich 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 call for a Gro inspection prior to grouting and a final inspection. <br /> Signed X Title: ai6il Date: . <br /> A— (Draw Plot Plan on Reverse Side)Fn� t �. <br /> s,,. - �— T:� FOR DEPA TMENT U E ONLY <br /> PHASE [ <br /> Application Accepted By Date g <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Final Inspection —7 <br /> ' Inspection By Date Inspection By Date / ,;-,- <br /> # /yI e-11' c7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT A 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 <br /> LESS <br /> PRORATION T <br /> f PLUS r <br /> PENALTY <br /> OTHER E <br /> I OTHER <br /> Received by Date Receipt No. - Permit No, .Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9521/1 <br />