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Applications Will Be Processed When Submitted Properly Completed. Be Sure To S�h&ApplScWrorT_ <br /> FOR`t;?FFICE USE: APPLICATION �g ry 1980 <br /> n <br /> (For Non-Transferable, Revocable, Suspendable) M 1980 <br /> AR d <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> i <br /> Application is hereby made to theSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with S n Joaquin County Ordinance No.1862 and the ru es nd regulations of the San Joaquin Local Health District. Q <br /> Exact Site Address f City/Town Z,113C A Ao-u i <br /> Owner's Name Phone 3 —, ] <br /> Address City 45C )_0 ,V <br /> Contractor's Name �• �i1 License#t710/t/U Business Phone—9 d`a,7 <br /> Contractor's Address ?t9[]3_fxQ by Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I _A No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR I I <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 TYPE OF WELL CA <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation l <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing J <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done mw Pli <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <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 N <br /> 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 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 w' all for a Grou nspe ti n prior to grouting and a final inspec' n. <br /> Signed X Title: L Dater - <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B - Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection B f Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br />' BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - <br /> F Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AYE.,P.O.Box 2069 STOCKTON,CA 201 <br />