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Applications Will Be Processed When SubmittedProperlyGompletea. be aure Io moIgw ++++ •+Nl+ .a ..,,• i <br /> FO OFFICE USF APPLICATION <br /> (For Non-Transferable, Revocable, 5uspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br />'Y made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 77 <br /> Exact Site Address City/Town <br /> PeI r <br /> Phone <br /> Owner's Name iv' _ Q <br /> City <br /> Address <br /> Contractor's Name License# �� Business Phone <br /> Contractor's Address/ mergency Phone � '� + <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 M--PUMP REPAIR❑ <br /> REPLACEMENT El I <br /> DISTANCE TO NEAREST: Septic Tank _7,,. _- <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Fielder t Cesspool/seepage Pit �� Other G <br /> Property LinelaPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1 C-IrOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t <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 Seal installed By: IF <br /> PUMP INSTALLATION: Contractor& J t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 the work for which this permit I <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 shail employ persons subject to workman's compensation laws of California." <br /> r I ill call for a Grout I p tion prior to grouting and a final inspecti <br /> r Signed X Title: Date: Z <br /> 'It (Draw Plot Plan on R ers�Sde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I \1�)F, . C�" <br /> Application Accepted By v"I�'� Date <br /> t Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> � 'r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1_&,Received By January 31 ❑ JulyReceived By July 31 - <br /> REMIT <br /> �r <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> L.' DATE DATE REMITTED AMOUNT <br /> i. FEE } � C/V �• ����f~ - .. <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> OTHER r�j lL <br /> OTHER � # _ <br /> Y s a <br /> Receipt No. Permit No. +. ssuan Date Mailed �. D vered <br /> Received by Date P F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKTON,CA 95201 <br />