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' Applications Will Be ProcessedWhensubmntea rroperry11.omPleccu.nc aurc IW—d- I ^rr•• -•- <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 /> made in compliance with S n�giaquin C unty Ordinance No. 1862 and the r les and regulations of the San oaquin Lo al Health District, <br /> Exact Site Address City/Town - <br /> � �t` a E tr <br /> Owner's Name 0- Phone�z_ <br /> City IN <br /> Address <br /> Contractor's Name License# yy Business Phone 7 1 <br /> Contractor's Address 0 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ ��5 No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCT_ION❑ ---r� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR Cl <br /> REPLACEMENT❑ J/ <br /> DISTANCE TO NEAREST: Septic Tank loo Sewer Lines Pit Privy <br /> mm Sewage Disposal FigId tr�Q `i__ Cesspool/Seepage Pit r .e. I _ -_ Other <br /> Property Lineo Private Domestic Well Public Domestic Well �- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 'CABLE TOOL Dia. of Well Excavation <br /> �/ <br /> IKDOMESTIC/PRIVATE ❑ DRILLED -Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN � Gauge of Casing <br /> ❑ IRRIGATION 1-1GRAVELPACK Deptli'of Grout Seal <br /> ❑ CATHODIC PROTECTION 1:1 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL �8urfa a Seal Installed By: Un <br /> r- <br /> . . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter F 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 forwhich this r <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> 1 will c tl for a Grout Inspection prier to grouting and a final inspection. tl <br /> Signed X m 9..�—NA an Title: � Date: <br /> (Draw Plot Plan on Reverse Side) r <br /> � 4 � <br /> FOR DEPARTMENT�USE ONLY <br /> PHASE 1 \}11. <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection / <br /> Inspection By Date <br /> �� y Inspection By�l Date 7 I r-2- <br /> d By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ JuVy 1 &Receiv REMIT my 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �j <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. i uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boll 2009 STOCKTON,CA 95201 <br />