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' Applications-Will Be Processed When Submitted Properly Completed. reToSignTheAppilcauog.Ijj <br /> FOR.OFFICE USE: APPLICATION111UG 19$0 <br /> (For Non-Transferable, Revocable,Suspen a le) <br />$f PUMP&WELL f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAS I jCnsP_,�i� f i0AL I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �AL p�STRiCT = <br /> Application is hereby made to the San Joaquin Local Health District,for a permit to construct and/or instal ework herein described.This application is <br /> made in compliance with San Joa UP County Ordinance No.W2 and the rules and regulations of the San Joaquin OcalHealth District. <br /> Exact Site Address r:� �t-1�� `—� City/Town �- <br /> Owner's Name <br /> ,4 Phone C <br /> Address [� �. City 4 i ' <br /> Contractor's Name T�_a/•Sr�ij+ c Sd� License# Business Phone �'• �■�� <br /> Contractor's Address ��)� <br /> t Emergency Phone 'Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- /-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REP.LACEMENTP <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 Weil <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL :, 11CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing y <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 <br /> San Joaquin Local Health District. <br /> regulations of the S q <br /> g <br /> Homeowner 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 lorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> wil II for a Grou nsp on-prior to-grouting and a final inspec' n. <br /> L-- <br /> Signed X - .- - ' <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO SPAR ENT USE ONLY <br /> PHASEI # <br /> Application Accepted By Q Date U" <br /> Additional Comments: <br /> Phase 11 Grout Inspection 6ase III Final Inspection <br /> Inspection By Date Inspection By Date` <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &R eived 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 /> ' EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER. <br /> OTHER <br /> - o <br /> [r[ Received by Dae Receipt No, Permit No. Issuance Date Mailed Delivered <br /> 4: APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 200' STOCKTON,CA 95201 <br />