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Applications Will Be Processed When Submitted Properly Completed. Be Sur Sim 7�p -. <br /> FOR OFFICE USE: APPLICATION l sI 1 ]( <br /> (For Non-Transferable, Revocable,Suspendable) PUMP& <br /> & <br /> t! <br /> ENVIRONMENTAL HEALTH PERMIT APf{ 1981 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � <br /> a <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install tH�Wrk 4elei 1�� Snb� 'T application is <br /> made in compliance with an Joaquin County Ordinance No. 1862 and the rules and regulations of the S r 6fi4gSkUD'`�K+44Aj -listrict. <br /> Exact Site Address r �o City/Town <br /> Owner's Name Phone <br /> Address City _ <br /> Contractor's Name = _r/ License# 14�` Business Phone S <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation 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 l PUMP REPAIR L7 <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 /> ❑ INDUSTRIAL ❑ 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: rte, <br /> PUMP INSTALLATION: Contractor < <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: dState Work Done <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 <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 <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 <br /> rouutt�ing and a final inspection. <br /> Signed X /S Cr�,xvl J b�i�.� G ,t v.� Title: 2279�f� Date: <br /> (Draw Plot Plan on Reverse Sid— <br /> ®, FOR DEPARTMENT USE ONLY ff <br /> PHASE I l7 <br /> Application Accepted By —� Date' <br /> Additional Comments: Zy� <br /> Phase II Grout Inspection a III Firyl Inspection <br /> `� — <br /> Inspection By t_ . Date Inspection By Date ® 61, <br /> Fee Is Due: ❑ ANNUALLY 1 r❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 64 3 ILI .-7 e <br /> Received by Date Receipt No. Permit No. Iss ance bate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br /> i <br />