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Applications A Will Be Processed When Submitted Properly Completed.Be SureTosignTheApplication. <br /> PP _ <br /> . use �. ... . <br /> A'PPLI <br /> FOICATION <br /> _s (For Non-Transferable, Revocable, Suspendable) '" PUMP&WFLI <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> (COMPLETE IN TRIPLICATE) # WATER QUALITY <br /> Application is hereby made to the San Joagkain Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co my Ordinance o,1862 a d the rut s and regulations of the San Joaquin Local Health District. <br /> 17 Cit /Tow W r� <br /> Exact Site Address Y <br /> Owner's Name a��r� Phone ' <br /> Address __ City <br /> Contractor's Name <br /> License#i r.V07/01 Business Phone <br /> Contractor's Address is ? (If ��Y��57`(�Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> I` DISTANCE TO NEAREST: Septic Tank /00 Sewer Lines Pit Privy <br /> Sewage Disposal Field /00" Cesspool/Seepage Pit Other. <br /> Property Lire Private Domestic Well Public Domestic Well <br /> r INTENDED USE I TYPE OF WELL �r Ori <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> it <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 166 <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 />�. TType of Pump H.P. <br /> PUMP REPLACEMENT: 0 State Work Done <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 /> 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 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 forwhich this <br /> t permit is issued, I shall employ_persons subject to workman's compensation laws of California." <br /> I I will call for a Grout Inspec' In prior to grouting and a final inspect'on. r <br /> Signed X r Title: Date: �I <br /> (Draw lot Plan on Rev se Side) C <br /> FOR DEPARTMENT USE ONLY <br />( PHASE I j� / <br /> Application Accepted By / tem.._.�_! r Date <br /> Additional Comments: f _ <br /> sR�(I Grout Inspection Phase til Final Inspection <br /> Inspection By 00 d6" Date Inspection By X/,;, Date % <br /> 1 Fee Is Due: ❑ ANNUALLY .❑ PER UNIT ❑ PER SITE. ❑ EACH ❑ January 1'8 Received By January 31 . ❑ July 1 &Received By July 31 <br /> REMIT <br /> IBILLING REMITTANCE_ 5 <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT OUE AMOUNT— ' <br /> FEE X43 <br /> LESS w' <br /> PRORATION <br /> PLUS <br /> PENALTY y <br /> OTHER <br /> OTHER <br /> Received by Date 'Receipt No. Permit No - •- -Issua ce OERe Mailed Delivered <br /> '' - - APPLICANT—RETURN ALL COPIES TOENYIR4NMENTAL HEALTH PERMIT75ERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON'CA 95201 - <br /> y <br /> i <br /> f ' <br /> r <br />