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Applications Will Be Processed When Submitted Properly Completed.BeSureToSignTneAppucanan <br /> FOR OFFICE USE, APPLICATION _ <br /> - (For Non-Transferable, Revodable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San`Joa um Local Health District. <br /> Exact Site Address City/Town <br /> r. Phone a, <br /> Owner's Name . <br /> Address ,I. _,,.r. --. .• "" _ City <br /> Contractor's Name oc Z .�r" S' License#��� `�'9 Business Phone' ✓�' Z��'� - <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WEL '� DEEPEN ❑ RECONDITI DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT OTHER 0 PUMP INSTALLATIOf�.- _,PUMP REPAIR❑ 4. .� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: ; Septic Tank Z _ Sewer Lines Pit Privy _� if <br /> - <br />' Sewage Disposal Field Cesspool/Seepage Pit >-, 7, lO'ther <br /> Public Domestic Well <br /> y 1 v.N�Nr �es }ri�rJ�c <br /> Line <br /> Private Domestic WeN <br /> INTENDED USE J TYPE OF WELL <br /> 11INDUSTRIAL ❑ CABLE TOOL _ _ _Dia. of Well Excavation <br /> J9 DOMESTIC/PRIVATE ❑-DRILLED - Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / }: <br /> 121 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal _a1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP.INSTALLATION: Contractor <br /> Type of Pump - h H.P. <br /> ` PUMP REPLACEMENT: 13State Work Done <br /> PUMP REPAIR: C1 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter. <br /> ` Approximate Depth <br /> r Describe Material and Proce{1}Ire <br /> y � I h reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 68nances, state laws, and rules and regulations of the San Joaquin Local Health District. r <br /> -Home owner or licensed agent's signature certifies the following:"l certify that tri tfie performance of the forwhichthis 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 /> >JV 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, l shall employ persons subject to workman's compensation laws of California." 1 .� <br /> 1 wilt call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X - <br /> Title: Date, <br /> �1�-= °J! <br /> (Draw Plot Plan on Reverse Side)— <br /> ii-FOR <br /> ide)— <br /> I_FOR DEPARTMENT USE ONLY <br /> PHASE I ) pate `F^� <br /> Application Accepted By <br /> Additional Comments: <br /> P s Grout Inspection / Ph iiiip 141 Final Inspection <br /> Inspection,By Date. .%�` - Inspection By N+ Datey <br /> Fee Is Due: ❑,ANNUALLY ❑ PEi '"❑ PER SITE ❑ EACH ,❑ 'January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuiy 31 <br /> �x <br /> � - BILLING REMITTANCE.,, $ AMOUNT DUE CHECKED ' <br /> t BASE —EXPLANATION-� ---'�DATE� DATE REMITTED AMOUNT <br /> 1 <br /> FEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> '( PENALTY NC <br /> OTHER t a_ <br /> OTHER <br /> '�-�-----i - I suance. ate Maiiii ,�.Deiivered_ <br /> Received by Date Receipt No Permit No. '� „__ ,ri , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />