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. ,v _.. ... <br /> Applications Will Be Processed Whan &dxnilted Proper y omp <br /> IOK10r�ic u9t: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or instail the work herein described.This application Is j <br /> ith San Joaqui Co int Ordin�ance�No. 186 and the rules and regulations of the San Joaquin Local Health District, <br /> made in compliance <br /> E Exact Site Address -• �, _�- '' '-�� _ i <br /> Phone <br /> Owner's Name - —1 City <br /> f Address <br /> Business Phone <br /> Contractor's Name - icense f# <br /> Contractor's Address TdW �G ,Com— Emergency Phone <br /> Is Certificate of Workman's Gompensalion ins n m on File With SJLHD7 Yos No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13RECDyyNDITIDN❑ DESTRUCTION❑ <br /> „ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Jml PUMP INSTALLATION❑ PUMP REPAIR❑ ""' <br /> REPLACEMENT❑ <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 /> i <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 i ❑ GRAVEL PACK Depth of Grout Seat <br /> i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> k <br /> )(GEOPHYSICAL Surface Seal Installed By: ^ <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done �...- <br /> DESTRUCTION OF WELL: Well Diameter Approx' at Depth <br /> i Descri a Mat rial and Procedure <br /> I I U <br /> 4 hereby certify that I ha'v epared this app Icati n and that t 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 /> I <br /> Home owner 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 forwhich this 1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final Inspection. ` <br /> Signed x� <br /> Title: Date: ' - <br /> (Draw Plot Plan on Reverse Side) � <br /> f <br /> I a FOR DEPARTMENT USE ONLY <br /> PHASE 1 Q C Date �� <br /> Application Accepted By 1, <br /> Additional Comments:— <br /> Phase 111 Final Inspection <br /> Ph a Il Grout ins ectl <br /> Inspection By Inspection By Hate <br /> j Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8,Received By January 51 © July 1 &Received 6y JUIy 31 <br /> f REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE. CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PLNALIY <br /> OTHER I \ <br /> OTHER l — <br /> Received y Dal Receipt No. Pefmtt lo. / Issuance Dale Mailed Delivered <br /> ..Or tf eNT_'nrTURN ALL COPIES TO: ENVIRONMENTAL HEALTI1 I-CRMIT(3111VICE5 1601 E."AZCLTON AVE.,P,a.Box 2009 STOCKTON,CA 952G1,., - <br />