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IAA licfatla s Will Be Processed 3 NeiriiSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> n e' <br /> 1 9 i <br /> 3 '40 (For Non-Transferable, Revocable,'Suspendable) SUMP&WELL <br /> Ski . �ki .ENVIRONMENTAL HEALTH PERMIT <br /> (COMPUETE IN TRIPLICATI )-j s H D)S,R!CT WATER QUALITY Y �, *tib <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work.herein described.This application is <br /> made in compliance with San Joa uin County grdinance No. 1862 a t�h�J rules and regulations of the Sa Joaquin ocal Health District. <br /> Exact Site Address a 1 &J R ur t� o "� City/Town is a/0%, <br /> Owner's Name _ }�i�" 4- Phone "" 27f <br /> Address '"?! _ City <br /> Contractor's Name 4 J "' S0 A) License#fie Business Phone <br /> Contractor's Address ` Emergency PhoQ PA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No } <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT® <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 a TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> T Type of`Pump H.P. _ _ a— <br /> PUMP REPLACEMENT: Ck State Work Done "�r _ 54 ,4 9 <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> 4 ordinances, state laws, and rules and regulations of the San Joaquin Local,Health District. <br /> 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 /> w' call for a Grout M.Pection prior to grouting and a final insp on. <br /> Signed X - Title: T Date: <br /> (Draw Plot Plan on Reverse Side) + <br /> e <br /> F FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted y Date <br /> Additional Comment <br /> P s rout Inspection -M, , as III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> EEE 4 r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER . <br /> Received by Date I Receipt No. lbehTrn N6 L I - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> t <br />