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Applications Will Be Processed When Submitted <br /> PPLICAProperly <br /> TIOWCompleted.Be Sure To Sign The Application. <br /> FOR OFFICE USE: SIDMNED <br /> )v <br /> 60PhD�4 (For Non-Transferable,Revocable,Suspendable) PUMP <br /> ENVIRONMENTAL HEALTH PERMIT <br /> w WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) the work <br /> Application is hereby made to theSan Joaquin Local Hence No. 1862 and District for a rules and regulations oftthle San Joaquin)Local Heath Distr.This ict. Is <br /> made in compliance with San JoaquinCounty Osr t, �� City/Town <br /> Exact Site Address <br /> Owner's Name �' r` <br /> 4ji,1� Phone <br /> w N City <br /> Address — , License# l7�3r� Business Phone <br /> 4.e <br /> Contractor's Nam <br /> Contractor's Address 0102 � Emergency Phone Noi <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?RECONDITION❑ ED STRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well— <br /> INTENDED USE TYPE OF WELL <br /> 11CABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIAL <br /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 OTHER Other Information <br /> 11 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL � � <br /> PUMP INSTALLATION: Contractor ! ►� <br /> H.P. <br /> Type of Pump cm <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> IT PUMP REPAIR: State Work Done Approximate epth <br /> DESTRUCTION OF WELL: Well Diameter <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. v <br /> mit <br /> Homeowner ora licensed employ <br /> an persoure n in such mannerifies the )owing:"I as to becomeythat in the performance of the work subjectto workman's compensation for <br /> of California." <br /> is issued, I shall not emp y Y P <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 w 1 call for a Gro 00 r' r to uting a a final <br /> inspection.isle: r/ Date: <br /> -S/7/&-- <br /> Signed (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY n <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Kase III Final Ins ction <br /> Phase II Grout Inspection a y 4)ate 7 z'z"-,c- <br /> Inspection <br /> Z <br /> Inspection By <br /> Date .Inspection By <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl REMITJuly 1 8 Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Date <br /> Receipt No. Permit No. I suanc Date Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />