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Submitted Properly Completed. e ure <br /> Applications Will Be Processed When <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) � .: <br /> PUMP&WPL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> strict for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made tothe San Joaquin Local Health Di <br /> made in compliance with San Joaquin Countyrdinance No. 1862 and the rules and regulations of the San,,Joaquin Locai Health District. <br /> City/Town <br /> Exact Site Address <br /> e peec <br /> Phone 2' <br /> Owner's Name ^� ��d <br /> City <br /> Address <br /> Contractor's N me W��-_�' 11 <br /> License# Business Phone— r� <br /> Emergency Phone <br /> Contractor's Address V_ No <br /> Is Certificate of Workman's Compensation I,nsuraann File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL 'L'1 DEEPEN ❑ RECONDITION❑ INSTALLATIONDCTION <br /> ❑❑ PUMP REPRIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank e <br /> Sewage Disposal Field `Cesspool/Seepage Pit Other <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �rf <br /> ❑ I TRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> _ � G `.. <br /> pL7 OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing /Z <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <br /> 13 IRRIGATION ❑ EL PACK Depth of Grout Seal l <br /> 11CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ✓ <br /> PUMP INSTALLATION: Contractor H.P. <br /> i <br />� Type of PumpI <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter <br /> Approximate Depth <br /> DESTRUCTION OF WELL: — <br /> Describe Material and Procedure ag <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquinCounty <br /> i <br /> '� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> t <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> IIIIL _ is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California <br /> f Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work iorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill callfora Gr ut In pection prior to grouting and a final insp tion. _ <br /> 1��r i► .� � �J Date: GeG�c.St <br /> Signed X <br /> t (Draw Plot Plan on Reverse Side) <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE lA Date <br /> Application Accepted By d <br /> Additional Comments: <br /> 'Pha I Grout Inspection Phas � I Final inspection <br /> Inspection By Date <br /> Inspection By Bate <br /> O- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE v <br /> D <br /> LESS ~ <br /> PRORATION <br /> PLUS <br /> i PENALTY, <br /> OTHER <br /> OTHER <br /> • lss ance 1e Maiied Delivered <br /> I Received by Date Receipt No- Permit No. � <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENT HEALTH PERMITISERYICES. 1601 E.HAZELTON AVE.,P.O.Bo>t.2009 STOCKTON,CA 45201 <br />