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Applications Will Be Processed When Submitted Properly Completed. BeSureTotogn 1nempprl,p�� • <br /> FOROFFusE: APPLICATION <br /> Cokftp �� �. (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTWIDERMIT <br /> WATER QUALITY r <br /> (COMPLETE IN TRIPLICATE)Application is hereby made to San Joaquin Local Health District for a permit <br /> to construct and/or install the described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the ruses and regulations of the San Joa uin Local Health District.. <br /> City/Town <br /> '��_ <br /> Exact Site Address J <br /> (nZS. Phone <br /> Owner's Name 5>IKYP � p- <br /> e <br /> C C I/ City <br /> Address Dbo <br /> Contractor's Name ;O ., �� £t ' License# ir13 i Business Phone, <br /> Contractor's Address a Emergency Phone t <br /> No <br /> es <br /> Is Certificate of Workman's Compensation- <br /> 0Llura -DEEPEN ❑ceo Ith SRECONDITION DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW W , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION® PUMP REPAIR j <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other_ I <br /> Sewage Disposal Field r x tr <br /> Property Line Private Domestic Well Public Domestic Well <br /> I .� <br /> INTENDED USE TYPE OF WELL <br /> ® INDUSTRIAL <br /> I. ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> E3 IRRIGATION <br /> ' ❑ CATHODIC PROTECTION 13ROTARY Type of Grout <br /> F ❑ DISPOSAL ❑ OTHER Other Information <br /> iSurface Seal Installed By: <br /> C1i GEOPHYSICAL' �� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -Tt`✓ rHG H.P. 3 C� <br /> I ❑ State Work Done <br /> PUMP REPLACEMENT: � s f <br /> PUMP R6PAIRY ® State Work Done <br /> lij <br /> DESTRUCTION OF WELL: r Well Diameter <br /> . Approximate Depth <br /> { Describe Material and Procedure <br /> I hereby certify thatl 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 forwhich 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 shah employ persons subject to workman's compensation laws of California." <br /> j I II for a Gr u y� eci�.prie routing and a final inspection. <br /> Signed X <br /> e: Date: <br /> (Draw Plot n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY q <br /> PHASE I Date Id <br /> Application Accepted By <br /> Additional Comments: l <br /> Ph s 111 Final Inspection <br /> FInspection By <br /> Plias ll Grout Inspection Date <br /> Date Inspection By <br /> � , <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rece+v July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE.' EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE S o r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date <br /> Receipt No, - Permit No.-- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICESAof <br /> 1601 E.HAZELTON AVE.,P.O.BoK 2009 STOCKTON,�20 <br />