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Applications Will Se.,Processed When Submitted Properly Completed. Be Sure To Sign The Application. l <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r� <br /> �'�- •----'���� � - - - - <br /> TATER fR�UAIITY <br /> (COMPLETE IN TRIPLICATE)rl/DS v ±,.tJ C -� ''p r I <br /> Application is hereby made to the San Joaquin Local Health Districtfora per Itto construct and/or install the work.herein described.This application is <br /> made in compliance.with an Joa pin/County Ord'InaQpe N 1862 and the r sand regulations of the San Joa uin Local H alth istrict. I <br /> Exact Site Address !. C� ' City/Town <br /> Phone <br /> Owner's Name <br /> Address City - 7 <br /> Contractor's Name License# '2—% Business Phonel''`�� l <br /> Contractor's Address ~Y Emergency Phone r t , <br /> G. Is Certificate of Workman's Compensation Insurance on File With SJLHD'4, 6Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 0._,;`RECOND1T101�❑� DESTRUCTION❑ T -1 <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ -PUMP INSTALL�i_0 U MPPtEPAr ❑ <br /> REPLACEMENT <br /> � �• f �r �L °QQJJ - <br /> :. <br /> l^r•t r Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank t <br /> Sewage Disposal Field; i° Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Wells <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia:of Well Excavation <br /> i ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC t ❑ DRIVEN �,�Gauge of Casing' <br /> El IRRIGATION El PACK Depth of Grout Seal <br /> IType❑ of Gr <br /> ❑ CATHODIC PROTECTION , ROTARY out <br /> t ❑ DISPOSAL ❑ OTHER i Other Information <br /> i <br /> ❑ GEOPHYSICAL I Surface Seal,lnstalled By: <br /> I PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. r <br /> 4 PUMP REPLACEMENT: ❑ State WorkfDone <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> j Describe Material and Procedure <br /> hereby certify that I have prep�.red-this application and that the work will be done in accordance with San Joaquin County F� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's sign8ture 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 /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhichthis V <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t I ill call for a Grout In*pectiof-prior to grouting and a final inspection.�� <br /> 3 <br /> Title: (f7 Date: <br /> Signed X <br /> ' `Y r (Draw Plot Plan on Reverse Side) GQ� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE O21 <br /> " Application Accepted By �' Date <br /> Additional Comments: 1 <br /> Phase II Grout Inspection Phase 11! Final Inspection <br /> 1' { f Inspection By Date <br /> Inspection By � Date , <br /> i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑FPER SITE ❑ EACH ❑ January 1 &Received By January 31 [3 July 1 &Received By July 31 <br /> . - _ }. REMIT <br /> BASE: EXPLANATION BILLING REMITTANCE $ AMOUNT'DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ) 1 <br /> PRORATION t S <br /> PLUS :.. <br /> PENALTY <br /> OTHER _ <br /> OTHER ° ` F <br /> .513 <br /> Received by - 'Date - Receipt No.- - Permit No. - ssua ce Date Mailed.- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AYE.,P.O.Box 2409 STOCKTON,CA 95201 <br />