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, � - ... <br /> Applications Will Be Processed When Su APPLICATION <br /> FOR OFFICE USE: .J�— � - (For Non-Translerable,,Revocable,Suspendable) pUMP&WELL <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made totheSan Joaqun{LoC�ynancehNo. 1862andDistrict fora Phe rutlesandregula4onsofttheSa�JoaquinlLdcscHealdthTDistrhis aiplicationls <br /> made In compliance wit 5 Joaquin ou y�0 City/Town <br /> i Exact Site Address <br /> Phone <br /> Owner's Name City <br /> k Address r. o - - License#-� 'f�J� Business Phone <br /> Contractor's Name �' .,� Emergency Phone <br /> Contractor's Address No <br /> y Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes ❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 13 RECONDITION <br /> NDONMENT ❑ OTHER 13 PUMP INSTALLATION ' <br /> WELL CHLORINATION 13 WELL ABAPUMP REPAIR C1 <br /> i REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> ( Property Line Private Domestic Well <br /> f INTENDED USE TYPE OF WELL <br /> j ❑ 1N STRIAL 11 CABLE TOOL Dia. of Weil Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE # [I DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC [] GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ OTHER Other Information <br /> 13 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Do e <br /> f PUMP REPAIR: <br /> 13 State Work Done <br /> CWell Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> # Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> j 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:"1 certify that in the performanceofthe 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 <br /> signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k <br /> I will <br /> all f Grout Inspe ion for to grouting and a final inspection. _ <br /> r-u1 Date,�. <br /> . - Title: - <br /> Signe (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - Date Z.. <br /> Application Accepted B <br /> Additional Comments: Phase I11 Final Inspection <br /> Phase 11 Grout Inspection Date Z: <br /> Inspection By <br /> Inspection By <br /> Date <br /> EMIT <br /> BILLING <br /> 3 ❑ ❑ PER UNIT C3 PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> I PLUS ' <br /> PENALTY - <br /> I OTHER <br /> i <br /> i <br /> I OTHER AA1 -Y <br /> , Permit No. I uance Date Mailed Delivered <br /> Received by Date Receipt Na. <br /> 1601 E.HAZELTON AVE,,P.O.Bax 2009 STOCKTON,CA 9 <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />