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Y' Applications Will Be Processed When SubmittedProperlycompiemo.ne surer 0.y11 r,r�Rrr• -• - <br /> FOR OFFICE USE: APPLICATION <br /> I' (For Non-Transferable, Revocable,Suspendabie) PUMP&WELL <br /> �'• ENVIRONMENTAL HEALTH PERMIT <br /> ,l I. WATER 4 UALITY <br /> (CIN TS`% �F• T ZSp —otPLi /��L <br /> OMPLETE TRIPLICATE) . � `+ . ` <br /> an Joaquin Local Health District fora permit to construct and/or install the work herein described.This ap <br /> Application is hereby madeto 4he Splication is <br /> i-: <br /> t lity Ordinance NS. 1862 and the rut sand regulations of the San Joaquin Local lth District. <br /> made in compliance with San Joag6h,'.'ou <br /> I Exact Site Address '— City/Town <br /> Phone <br /> Owner's Name <br /> City <br /> Address ' <br /> Contractor's Name <br /> License# r22'11'0 3 Business Phone 57—x`?5 <br /> ' Contractor's Address r~3So2� ��a/�/z�� Emergency 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❑ C <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i <br /> t DISTANCE TO NEAREST: Septic Tank 7LQ Sewer Lines Pit Privy <br /> Sewage Disposal Field Q`fi Cesspool/Seepage Pit Other <br /> C Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / <br /> i <br /> 11 INDUSTRIAL - ❑ CABLE TOOL Dia. of Well Excavation <br /> Jcv DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - /''&i�P��� <br /> ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing <br /> 13 IRRIGATION JA GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout . <br /> I ❑ DISPOSAL ❑ OTHER Other Information 3 <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C/ <br /> I� Type of Pump H.P. (� <br /> PUMP REPLACEMENT: •I <br /> 'El State Work Done <br /> PUMP REPAIR: u ❑ State Work Done <br /> DESTRUCTION OF WELL: !I Well Diameter Approximate Depth C <br /> Describe Material and Procedure <br /> F l 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 performanceof the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject fo 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grou,It Inspection prior to grouting and a final inspection. <br /> - <br /> Signed X Title: k Date: <br /> it {D�wPlt�Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE Ih 14 rC?.� 07II <br /> Application Accepted By, Date <br /> Additional Comments: . <br /> Q!r ro t In_speclion/7 Phase III Final Inspection <br /> Inspection By `'!r_ ` Date 1�` Inspection By Date <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 . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - ate Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA95201 <br />