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r -- ­u <br /> Applications Will Be Processed When Submitted Properly Completede u <br /> re <br /> FOR OFFI USE: APPLICATION <br /> (For Non-Tran§ferable,Revocable;Suspendable) r PUMP&WELL <br /> ' YENVIRONMENTAL HEALTH PERMIT rI <br /> �I�IfATFuAIITY <br /> (COMPLETE IN TRIPLICATE) =2 �a t G S: c and/or O" a <br /> Application is hereby made to theSa'nJoaquinLocalHealthDistrictforaperml to construct installthework herein described"7hisapplication is <br /> made in compliance with San Joaquin County Ordinance o. 1 62 and the y�les and r g lations+of the San J aquin Local Health District. <br /> �� .p G k l r et C <br /> City/ <br /> Exact Site Address Town <br /> I I '� r <br /> Phone"'... ' h <br /> r Owner's [Name Cit <br /> Address <br /> Contractor's Name <br /> f <br /> License* 1% Business'Phone Z <br /> ,lwi, " 'Emergency Ph ne . ' r. <br /> Contractor's Address <br /> No <br /> Is Certificate of Workman's Compensation*Insraneeon File With SJLHD? Yes TYPE OF WOfiK (CHECK): NEW WELDEEPEN ❑ u ' REC, ND1T10N❑ DESTRUCTION D <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER u PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> i �S <br /> REPLACEMENT❑ l Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank '�-�— Sewer Lines �^�- y <br /> Sewage Disposal Field �-- Cesspool/Seepage Pit Other <br /> YI - Private Domestic <br /> Public Domestic Well <br /> Property.Line f <br /> INTENDED USE �ITYPE OF WELL <br /> El INDUSTRIAL I 11 CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of We,11 Casing <br /> ❑ �—^ <br /> DOMESTIC/PRIVATE j f.- ,�,^,r,,,-,-� ^�-• <br /> (( ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC 4 • ' <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 1:1 IRRIGATION <br /> Q <br /> ElCATHODIC PROTECTION ROTARY Type of Grout j <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> • <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I � <br /> PUMP INSTALLATION: Contractor v Q <br /> H.P. <br /> Type•of Pump s ( , <br /> PUMP REPLACEMENT: ❑ State Work Done ( L <br /> PUMP REPAIR: i ❑'State`Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure f <br /> I hereby certify 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, 1 shall not employ any person in such manner as to become subject to wdrkman's,compensation laws of California." .. <br /> Contractor's hiring onsub-contracting signature certifies the lollowing:"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 call for a Grout:Inspection prior to grouting and a final inspection. <br /> Signed X <br /> I Title: Date: <br /> 4 (Draw Plot Plan on Reverse Side) I <br /> U - <br /> i' FOR DEPARTMENT USE ONLY <br /> PHASE 1 � pate -7. Q�`L-- <br /> add`` <br /> -� Application Accepted By <br /> Additional Comments <br /> r Phrase II Orout-Inspection e 5 Phase 111 final Inspection r <br /> - *w �� � , Inspection Ely � :•.Date <br /> pinspection By <br /> _ Date <br /> t �/UfC <br /> Fee IS Due: ❑ ANNUALLY'- ., PER UNIT° PER ITE ❑ EACH January t &rSeceived By'January 31 " ❑ July 1 &Received By July 31 <br /> REMIT <br /> ' II l BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED, AMOUNT <br /> FEE <br /> LESS �I <br /> PRORATION <br /> PLUSPENALTY <br /> OTHER �. <br /> OTHER <br /> OTHER . .. --` - y <br /> s <br /> DateReceipt-No.'- _ Permit No. Issuanc Date Mailed Delivered <br /> Received bytfi01 E.HA2ELTON AVE.,AYEP.O.Box 2009 STOCKTON,CA 35207 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> — <br /> H <br />