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- Applications Will Be Processed When Submitted Propeny t,.omple�cu. WW �ti�� --•W <br /> APPLICATION, <br /> Y <br /> FOR OFFICE USE: <br /> {For Non-Transferable, Revocable, Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY -- <br /> (COMPLETE IN TRIPLICATE) <br /> Appiication'is hereby made to the San Joaquin'Local Health District for a permit to construct and/or install the work,herein described.This application is <br /> made in compliance with County Ordinanc No. 1862 and the r es and regulations of the San Joy�quinaHealth District. <br /> -� Y City/Town <br /> Exact Site Address <br /> LIi�-V Phone 7• s0 — �f <br /> OWner'S Name <br /> � �� City <br /> Address ora <br /> License - Business Phone <br /> Contractor's-Name � ';.= <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation 1�surance on Fil?With JLHD? Yes No <br /> NII <br /> TYPE OF WORK (CHFCK-):_ NEW WELLIX DEPEN❑❑ OTHER REO❑RECONDITION. Q <br /> P INSTALLAT ON/� PUMP REPAIR❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT <br /> r [� <br /> REPLACEMENT❑ <br /> Pit Privy _/ <br /> —/ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line -" Private Domestic Well Public Domestic Well <br /> _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> C <br /> � �RQMES7IC/PRIVATE - ❑ Dia. of Well Casing <br /> DRILLED Or <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ElGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL 13 OTHER Other Information <br /> 1:1 GEOPHYSICAL' Surface Seal Installed By: <br /> PUMP INSTALLATION: Cohtractor <br /> Type of Pump b� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11 State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> ( <br /> t <br /> at the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this ap <br /> plication and that <br /> i Joaquin Local Health District. <br /> ordinances, state laws, and rules and regulations of.the San <br /> # Home owner or licensed agent's signature certifies the following:"I certify that in the performance o!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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> rmit is:issued, I shall employ persons subject to workman's compensation laws of California." r ` <br /> ` 1 will 11 f rout Inspe n prior to grouting and a final iry�pect n. 7 <br /> Title[.` D Date: <br /> Signed X, <br /> (Draw Plot Plan on Reverse Side) a <br /> F R DEPARTMENT USE ONLY <br /> P Y PHASE.I DIate 77 <br /> Application Accepted By <br /> Additional Comments: <br /> P ase 111 Final fns eclion 7� <br /> l •.P ase H Grout In tion <br /> ' Ce�'�ate I — Inspection By Date <br /> Inspection <br /> By <br /> Fee Is Due: ❑ ANNUALLY�: ❑ PER UNIT PER 517E ❑r EACH 0 January 1 &Received By January.31 "❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE. - EXPLANATION DATE DATE REMITTED AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> S ' <br /> PLUS <br /> ~ PENALTY - <br /> OTHER <br /> OTHER <br /> D to Receipt No.` Permit No, :tall) <br /> e Mailed Delivered <br /> F <br /> Receiv 6y <br /> Y M,1601 E.HAZELTON AYE.,P.O.Boa 2409 TSTOCKTON,CA 95201 <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ;2 <br />