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-k _1impper-all <br /> Applications Will BesProcessed When Submitted Properly Completeu <br /> ii <br /> FOR`,, ICE USE: APPLICATION 7 <br /> (For Non-Transferable, Revocable, Suspe ? APR15 1901puMP&WELL <br /> } <br /> ENVIRONMENTAL HEALTH PERMIT <br /> !-• A 9 <br /> y WATER QUALITY SAS it �t � 9AL <br /> (COMPLETE IN TRIPLICATE)" !!���� r}�'bed.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit construct and/or ins�IY�o�o hdeth ��s <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> �, i, 4- I4 I City/Town � <br /> Exact Site Address <br /> Phone� <br /> Owner's Name �/ i r (�.x City <br /> Addresl#�� City _ <br /> Contractor's Name E. <br /> i, 5 r �r,I++�'A License#/ �.� Business Phone `7 5 <br /> Contractor's Ad� s�_ _[� a� f�*��- � - Emergency Phone 7y3 ' 1 '2 y � <br /> is Certificate of Workman's Compensation Insurance on File With SJLHI Yes NO <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ems' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /Qi Pit Privy 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other a <br /> Property Line4mt!e_tZ�, Private Domestic Well Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation T <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1:1IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br />' ❑ CATHODIC PROTECTION 16 <br /> ROTARY Type of Grout 1` <br /> ❑❑ <br /> DISPOSAL OTHER Other Information I <br /> Seal Installed B <br /> ❑ GEOPHYSICAL Surface Se : <br /> Y <br /> PUMP INSTALLATION: Contractor - � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: C3 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ; <br /> .Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County s <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will calf for a ii Inspection prior to grouting and a final Inspection. 10 3 <br /> 44 <br /> Signed X — <br /> Title: _ Date, <br /> (Draw Plot Plan on Reverse Side) -0 <br /> FOR DEPARTMENT USE ONLY ) <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase I Grout Inspection III Final Inspection <br /> Inspection By <br /> ate r Inspection By Date 2� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received MlTBy uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> [ OTHER <br /> OTHER r { <br /> c eived by Date Receipt No Permit No. Issuance Date fled slivered <br /> Received <br /> i; <br /> �, APPLICAIIRETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9520 - <br />