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� r►R <br /> Applications Will Be Processed When Submitted Properly omp e e <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspend �) PUMP& <br /> 1r ENVIRONMENTAL HEALTH PER Qu G 1951 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) �t de, fd.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in �iNhe" <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations o Ivr L1 } %J <br /> p��alth District. <br /> e i A." City/Town o <br /> Exact Site Address 10 <br /> � � Phone <br /> Owner's Name City <br /> Address 2 17 3� Phe <br /> Contractor's Name License#��� Business on —��—' <br /> Q Emergency Phone <br /> Contractor's Address 1 <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> 4 <br /> TYPE OF WORK (CHECK): L ❑ RECONDITION❑ DESTRUCTION <br /> NEW <br /> OTHER 13 P INSTALLATION—~PUMP REPAIR❑ C, <br /> WELL CHLORINATION <br /> r� <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> CesspoollSeepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,fMUSTRIAL E3 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED 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 Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> ,T,y e of Pump <br /> PUMP REPLACEMENT: estate.Work Done <br /> PUMP REPAIR: 11 State Work Done `4' <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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, 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 /> o / Date: <br /> Signed X — a. ' � '�` �� Title: <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �{ <br /> PHASE 1 re-r Date <br /> Application Accepted By ' <br /> qj <br /> Additional Comments: se tll Fi <br /> Phase 11 Grout Inspection <br /> Inspection By Date Inspection <br /> ❑ ❑ PER SITE ❑ EACH ElJanu J &Re ed By January 31 ❑ July 1 &Received BMyl July 31 <br /> Fee Is Due: [I ANNUALLY PER UNIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE RE TTED C AMOUNT <br /> • FEE <br /> LESS L <br /> PRORATION <br /> PLUS <br /> PENALTY ` <br /> OTHER <br /> OTHER <br /> D(p <br /> Permit No. I uanc Data Mailed Delivered <br /> Received by Date Receipt No <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 S7OCKTON,Co <br /> A 95201 <br /> APPLICANT— ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ��-• <br />