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Applications Will Be Processed.When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> FOR OFFICE USE: APPLICATION ; <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRI PLICAT E)MV-3-g"`;!E7 -&C- -rte �R QUALITY22 -?—V� <br /> Application is hereby made toth SanJoaquin•Loca1HealthDistrictforapermittoconstructand/or install the wor��endescrippoo,,bed. l�isapplicationis <br /> made in compliance,with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address . / E aG A'APJ7A �P Cn�ity/Town <br /> RP- <br /> Owner's Name Phone 3 s <br /> Address City d a f <br /> Contractor's Name _(,7fffSQL�—f�/ D /�/ �j License#3374YL Business Phone <br /> Cil <br /> Contractor's"Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- K _— No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 6<00e9 Sewer Lines Pit Privy <br /> I. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lined Private Domestic Well �— Public Domestic Well ^� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation / 3� r Q <br /> ❑ DOMESTIC/PRIVATEDRILLED 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 GroutVV <br /> —� <br /> ❑ DISPOSAL - ❑,OTHER -_A - Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> W <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter Approximate Depth ►" ... <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 <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, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will cal for a Grout Inspecti n prior to grouting and a final inspection. _ <br /> Signed X Title: _. ��. Date: fe?— ✓^`. �� <br /> ' (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y. <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection _ Ph a III Final Inspection <br /> a . Inspection By Inspection By'_^ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By'July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION' AMOUNT OUE CHECKED <br /> PATE PATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY , <br /> -HER <br /> 4 <br /> Date Receipt No. Permit No. Is uance Date Mailed D ivered <br /> '9ETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />