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r� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign a pplication. <br /> FoR.oFl USE: i APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) <br /> - , PUMP&WELL <br /> ENVIRONMENTAL_ HEALTH PERMIT r <br /> I <br /> ' . �.^ ATERQUALITY � 5 } =��0 6� <br /> (COMPLETE IN TRIPLICATE) W-`0 "- � i <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulatigns of the San Joaquin Local'Health District. <br /> i Exact Site Address <br />� <br /> Q Q�' Owner's Name - ._ Phone <br /> z` Address 1 iYd City <br /> Contractor's Name / /� License# ,-2908/3 Business Phone <br /> Contractor's Address G/1 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❑ �J <br /> WELL CHLORINATION 13WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ► ' <br /> _ DISTANCE TO NEAREST: Septic Tank �J�© Sewer Lines Pit Privy J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other L - 100 — <br /> 1 f Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 6 N <br /> ❑ INDUSTRIAL !I i 13,CABLE TOOL Dia. of Well Excavation /6 <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 1c11 DRIVEN Gauge of Casing <br /> f IRRIGATION GRAVEL PACK Repth,of Grout Seal AO�te <br /> ZrA e! <br /> ❑ CATHODIC PROTECTION ` -. O ROTARY Type of Grout <br /> 11 DISPOSAL t ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION:- Contractor, 4 <br /> { i Type of Pump H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done n} <br /> PUMP REPAIR: ❑ state Work Done 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .1 <br /> t� �v <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County- <br /> h <br /> r_ <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 thework for which this permit <br /> x is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contr1.actor'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 I spection prior to grouting and a final inspection. <br /> I 1 �• 51-,27 <br /> Signed X � Title Date: <br /> t (Draw Plot Plan on Reverse Side) <br /> it 1 <br /> �I FOR DEPARTMENT USE ONLY �Q <br /> PHASE I Date a "� <br /> Application Accepted By <br /> Additional Comments: <br /> �� Phase It Grout Inspection - Phase NI Fi I Inspection <br /> - Date. Inspection Bye Date �f <br /> Inspection By <br /> 'i . <br /> A '".' iil �' _ ='ti: ce ti_-. <br /> Fee Is Duel: ❑ ANNUALLY ' ❑ PER UNIT .❑ PER SITE' ❑ EACH ❑ January 1 &Received By January 31 '❑ July 1 &ReceivedREMITuIy 31 <br /> BILLING REMITTANCE $ <br /> BASE iEXPLANA710N AMOUNT DUE CHECKED <br /> i d -DATE DATE REMITTED AMOUNT <br /> ti <br /> r <br /> 1 FEE <br /> LESS l <br /> t PRORATION - - <br /> t PLUS <br /> 5 PENALTY f� <br /> OTHER <br /> OTHER <br /> ' ate Receipl No. - Permit No. Issuance Date Mailed Delivered <br /> Re eived by , <br /> I, APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boz 2009 STOCKTON,CA 95201 <br />