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Applications Will Be Processed When Submitted Properly Completes tse bore 1vo,v„ ^rte U-11 <br /> FOR OFFICE USE: APPLICATION / <br /> # (For Non-Transferable, Revocable,Suspendable) / PUMP &WI LL <br /> ENVIRONMENTAL HEALTH PERMIT ttt <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSanJoaquin <br /> LvO�admancehNost1862an rictfora phe rules and regulaermitto tioons oftthe San JoaquinlLocalcHealdihTDisthis rlpCp.lication Is <br /> made incompliance with San Joaquin County'OF PIP <br /> City/Town <br /> Exact Site Address f _ 6 f <br /> /' U� -G9y,�� Phone <br /> J <br /> Owner's Name City <br /> ZA, F7 <br /> Address �.yQz/ Business Phone <br /> '" � <br /> Contractor's Name 4 Emergency Phone ? O 7 1 <br /> Contractor's Address No v t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): <br /> NEW WAB ABANDONMENT ❑E] DEEPEN ❑ OTHER ❑RECONDITION❑P INSTALLATION ❑ PUMP REPTIONO <br /> WELL CHLORINATION ❑ W V <br /> REPLACEMENT Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Weil <br /> INTENDED USE 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 /> 5utface Seal Installed By: <br /> 13 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: <br /> Well Diameter . Approximate Depth ---. <br /> iDescribe Material and Procedurecertify that 1 have prepared this application and that the work will be done in accordance with San Joaquin CountyI hereb <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. C <br /> Homeowner or licensed agent's signature certifies the following:"l 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 tail for a Grout Inspection prj¢r to grouting and a final inspection. <br /> Title, � � �` � Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I Date <br /> ti <br /> Application Accepted By <br /> Additions! Comments: Pha II I nal Inspection <br /> J Phase II Grout Inspection Date 1.9 (OJ I <br /> inspection <br /> Inspection By :_` Date tion By <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER S4TE ❑ EACH ❑ January 1 31 Received By January ❑ July 1 &Receiv REMIT 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE w <br /> LESS <br /> PRORATION <br /> PLUS <br /> . t <br /> PENALTY <br /> OTHER <br /> OTHER {�1 <br /> Permit No 1 suance a e Mailed Delivered <br /> Received by Date Receipt No. <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> � <br />