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Applications Will Be.Processed When Submitted Properly complelea. i3eaura io aign ilianNNenuv„• <br /> APPLICATION <br /> F <br /> O 1 r <br /> (For Non-Transferable, Revocable, Suspendable) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 7767 City/Town —_71+0 1111112,11111111:111-l" 1,111 i-,Al <br /> Owner's Name Phone <br /> City D/t/ <br /> Address <br /> Contractor's NameLicense#��Business Phone <br /> ) 77 <br /> Contractor's Address A 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❑ t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERA PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> G�A Pit Priv "~! <br /> DISTANCE TO NEAREST: Septic Tank -- Sewer Lines Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lined Private Domestic Well Public Domestic Well <br /> I' INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r .IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r� <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> r-- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL 47�-ftr�lU� G�tSI�aBC, '/ Surface Seal Installed By: _ YLSi/�lc <br /> PUMP INSTALLATION; entr i� �� I � r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t 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 /> r Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 for which 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 and a final inspection. <br /> Title:. Date: <br /> Signed X <br /> i (Draw Plot Pian on Reverse Side) <br /> ^- �--- FOR DEPARTMENT USE-ONLY-'•"`-__4 - <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ill Final Inspection <br /> Inspection By Date Inspection B Dat <br /> i <br /> f- Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH '❑ January 1 8 Received 8y January 31 ❑ July i &Received By July 31 <br /> ` REMIT <br /> ` BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> l FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> - <br /> OT HER <br /> e � � <br /> OTHER - / <br /> Received by - Date - Receipt No. ., Permit No. Issuan a Dae Mailed Delfveted <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES (J <br /> , <br /> F' <br />