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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ; <br /> FOR OFFICE USE: APPLICATION : <br /> (For Non-Transferable, Revocable,Suspendable) 1 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WALL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is .T <br /> made in compliance with San Joaquin County Or inance No. 1862 and the rules and regulations of the San o uin L c I Health District. <br /> YZ <br /> Exact Site Address ' 7 City/Town <br /> Owner's Name Phone '731— s7 i <br /> Address w City <br /> i <br /> Contractor's Name _plLicense 41(-.2.373 Business Phone 42'1,6 '- Q4- <br /> Contractor's Address r �� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 J <br /> REPLACEMENT 0� <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 /> EI INDUSTRIAL 0I CABLE TOOL' Dia. Well ll Excavation <br /> 21DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal We- <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Ss rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: aState Work Done r t <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have preparea.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. t <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 for which this <br /> permit is issued, I shall employ persons subject'to workman's compensation laws of California." "' <br /> Y 0 <br /> 1 call r a Grout pection prior grouting and-aal.inspection. F <br /> Signed X - _ _ ..Title:YDate: fJ <br /> �- aw Plot Plan-.on Reve a Side) <br /> F R D PARTME T USE ONLY <br /> PHASEI s <br /> Application Accepted By Date 2� <br /> Additional Comments: _ <br /> Phase ll Grout Inspection ��- T Ph—ase III Final Inspection <br /> Inspection ByMI let Date inspection By Date `r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BkLLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4 y 3 <br /> LESS <br /> PRORATION <br /> PLUS .! <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />