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Applications Will Be Processed When Submitted Properly compimeo. oe auras rU01911 <br /> FOR OFFICE USE*. , :F1 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ` 30 <br /> .L, PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ` <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> 5 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is� <br /> rules and regulations`of t <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the he San Joaquin Local Health Distric <br /> CitylTown <br /> Exact Site Address <br /> Q <br /> T t�.&111141d Phone <br /> Owner's Name J City <br /> Address <br /> g ALicense # Business Phone <br /> Contractor's Name ► ► w <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insur a on File With SJLHD? Yes <br /> No � <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ a <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank //O r _ Sewer LI Pit Privy_. <br /> F Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line /B Private Domestic Well A.AG Public Domestic Well <br /> INTENDED�USE TYPE OF WELL <br /> ❑,.,., INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /a <br /> gi15'MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> AI <br /> 13-IRRIGATION M.-ER��AVEL PACK Depth of Grout Seal <br /> M <br /> 11 CATHODIC PROTECTIONType of Grout <br /> L3 DISPOSAL t OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: P <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> (' PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: 411stateWork Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l 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 becoriie subject to workman's compensation laws o1 California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will cqJI !9r a Grout Inspection prior to grouting and a final inspection. } <br /> Title: Date: <br /> Signed'X- <br /> i (Draw Plot Plari on Reverse Side) <br /> [ FOR DEPARTMENT USE ONLY <br /> ! PHASE I J 2-71Date <br /> Application Accepted By <br /> Additional Comments: <br /> a 1 Gr t Inspection Phase III Final Inspection <br /> Inspection By Date <br /> '1Zy Inspection By Date <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ly 31 S <br /> N BILLING REMITTANCE AMOUNT DUE CHECKED <br /> EICPLANAT40 <br /> BASE DATE DATE REMITTED AMOUNT <br /> t FEE <br /> R LESS r <br /> PRORATION <br /> i. PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER x- <br /> ')vJ <br /> ' 1 uan Date Mailed Delivered. <br /> Received by Date Receipt No. - Permit No. <br /> >.. - .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON.AYE.,P.O.BOX 2009 STOCKTDN,CA 95201 <br />