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Applications Will Be Processed When Submitted Properly Completed. � rt7foligfrTh`e�A4lic�-ioii <br /> FOR OFFlcFu$E: APPLICATION p�1 <br /> (For Non-Transferable, Revocable, Suspen a le) OCT 14 1980 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> JAS .It , ,;_ l,J .fi AL.. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i t r <br /> Application is hereby made to the San Joaquin Local Health District fora permittoconstruct and/or instJ1 417ork herelin described.This application is <br /> made in compliance with an Joaquin County Or¢ji . 1862 and the rules and regulations of the San Joaquin ocal H a (strict. <br /> Exact Site Addresses tllllCG�� Cit /Town �� <br /> Owner's Name i4�� 1� � a° 1'� Phone <br /> Address 5 " City <br /> Contractor's Name icense# Business Phone .� ) <br /> Contractor's Addres - Emergency Phonol <br /> Is Certificate of Workman's Compensat on Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�— rPUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1. 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 /> ❑- STRIAL.,,.._ ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �,1�"1 A 1 VL _ C a <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: I] State Work Done <br /> PUMP REPAIR: O-State Work Doner, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit T <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:1 certify that in the performance of the work forwhich this J <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I all for a Grout Inspec. prior t groutin and a final inspecti / <br /> I <br /> Signed X Title: ` Date: <br /> ` (Draw Plot Plan on REVirse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . :.,d� <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection has'e inal ection <br /> (a " . . <br /> Inspection By Date Inspection.B Date /Z <br /> a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s � <br /> Received by Date Receipt No. ermit No. Isdivance Nate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />