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' Applications Will Be Processed When'Submitted Properly Completed.Be Sure To Sign The Application. <br /> �,,. ,.,APPLICATfON <br /> 3 <br /> _' FOR OFFICE USE:i � ; .�,� <br /> (For Noxi-Transferable, Revocable, Suspendable) <br /> s, _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT" C <br /> t WATER QUALITY tion is <br /> I+ v. <br /> (COMPLETE IN TRIPLICATE) 4 r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applica <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules an `regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town Z <br /> Owner's Name sk y Phone <br /> Address <br /> _ License_# 6 Business Phone ' <br /> Contractor's Name - - - , <br /> Contractor's Address O 'er Emergency P onepr�> _r77. <br /> Is Certificate of Workman's Compensation Insuran a ori File WithSJLHD? Yes No <br /> TYPE OF,WORK (CHECK): NEW WELL❑7r DEEPEN ❑hSsR" RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL^ ABANDONMENT ❑ OTHER 11PR+ <br /> LUMP INSTALLATION ❑ I PUMP REPAI <br /> REPLACEMENT❑ _- r <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.t € <br /> INTENDED USE: T,,PE,OF WELL I <br /> Q INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ' <br /> ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing I = <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f r4 Na <br /> 11IRRIGATION 11 GRAVELPACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t+� <br /> Other Information, <br /> 1:1 DISPOSAL "� "❑ OTHER z _ s w ! <br /> ❑ GEOPHYSICAL ,, Surface Seal-Installed By:--� <br /> PUMP INSTALLATION: � Contractor <br /> y 'Type of Pump_ ' s H.P. . <br /> PUMP REPLACEMENT: ❑ State Work Done. <br /> PUMP REPAIR: State Work Done G . N <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Q <br /> ` p 5 <br /> Describe Material and Procedure _ <br /> I hereby Y certif that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.- <br /> Homeowner 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 will call for a Grout Inspectionlprior to grouting and a final inspection. <br /> Signed X Title: Date: ��l <br /> (Draw Plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i Date Iy d <br /> Application Accepted,By �' <br /> Additional Comments: ' <br /> Phase fl Grout Inspection Phase III Final inspection <br /> Inspection By Date Inspection By T Date ;, 8 () <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 ReceivedREMITuly,31 ' <br /> BASE EXPLANA-TyON BILLING REMITTANCE $ AMOUNT DUE CHECKED' ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE NY%b A <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER °pE <br /> Received by Date Receipt No.- -Permit No. seance Date Mailed Delivered <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESm.61401 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> "f } <br />