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Applications,Will Be Processed When Submitted Properly Comp e e e 1 { U <br /> APPLICATION <br /> FOR OFFICE usE: <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t , WAT£R.QUALITY III1..iq, A tr t.? t.. . <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described,This application is <br /> ig ,...- ,' � .s <br /> made in compliance with San Joaquin.County Ordinan a No.�862and the. uses and;re ulations of.the Sa Joaquin Local Health District. <br /> (� City/Town <br /> Exact Site Address Z <br /> �NIIt ` 't' I� 4 r Phone <br /> Owner's Name III �` r , ,., City. Ir " <br /> Address � � �— <br /> s.s{ z+ ' License#t3 .!-s= Business Phoneme ! <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address <br /> File With SJLWD Yes No <br /> is Certificate of Workman's Compensation insurance on e <br /> N <br /> TYPE OF WORK (CHECK): NEW WELL❑ DELPEN❑ OTHER EON❑DITIOP❑P INSTALLAT ON��PUMP REPRIR❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT <br /> REPLACEMENT❑ 3; Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ 1N9p&fRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> l OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El 'OTHER Other Information <br /> r ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL W <br /> PUMP INSTALLATION: ; Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: I ❑ State Work Done <br /> PUMP REPAIR: !� 13 State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> ! I <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will or a Grout"lnspection prior to grouting and a final inspection. <br /> t <br /> Title: .ate. Date- <br /> p Signed <br /> (Draw Plot Plan On Re erse Side) <br /> 13 - <br /> j , <br /> FOR DEPARTMENT USE ONLY , <br /> PHAS-71n I l0 <br /> Date <br /> FApplication Accepted ByAdditonal Comments: <br /> s Pha �.I1 nal Inspection <br /> Phase II Grout Inspection Date <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 ReceivedJuly 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> -- BASE EXPLANATION DATE PATE REMITTED AMOUNT <br /> FEE Q <br /> LESS jp - <br /> PRORATION <br /> PLUS <br /> PENALTY, - <br /> OTHER L <br /> 1 _ . <br /> OTHER <br /> Receipt No. Permit.No.-•-� 1 uance ate Mailed Delivered <br /> Date <br /> ' - Received by ;ti 1601 E.HAZE <br /> AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERMITlSERYICES <br />