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,. �.`. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. l w <br /> i FOR OFFICE USE: APPLICATION - <br /> " (For Non-Transferable, Revocable, Suspendable) <br /> +'= ENVIRONMENTAL HEALTH PERMIT 319X61 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> 1' made in compliance with San Joaquin Cou#ty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> F Exact Site Address City/Town <br /> 'lip <br /> Owner's Name �7dL Phone <br /> Address City <br /> Contractor's Name License# Business Phone <br /> I Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT. ❑ OTHER ❑ PUMP INSTALLATIONN PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> f - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 Othe(Finformation <br /> ❑ GEOPHYSICAL Surface Seal Installed By:-- <br /> PUMP INSTALLATION: Contractor - <br /> - . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter— le <br /> �� Approximate Depth <br /> Describe Material and Procedure i <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 call a Grout Inspection prior to grouting and a final inspection. <br /> Signed'X' ' <br />, Title: Date: — <br /> {Dmvv Plot Plan on Reverse Side) , <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By I Date <br /> Additional Comments: <br /> k <br /> Phase II Grout Inspection. P 11 Final spection i <br /> Inspection By Date Inspection <br /> By Date... i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 ` } <br /> Y Y Y El 1 &Received By:July'"3f <br /> REMITTANCE $ '• REMIT <br /> BASE EXPLANATION BILLING RE <br /> i <br /> DATE DATE REMITTED - AMOUNTDUE CHECKED; <br /> AMOUNT-'"- <br /> FEELESS <br /> k <br /> c a PRORATION <br />,i ,. <br /> PLUS j <br /> PENALTY # <br /> OTHER <br /> OTHER <br /> a� <br /> Received by - Date � � Receipt No, 'T -• errrtit N :. - I uance ate Mailed Delivered ? N <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH"PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 01� <br /> 1 <br />