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N 'Applications t Will Be Processed When Submitted Properly Completed. Be sure toatgn tn=..�g•4�I � <br /> APPLICATION 7 a� <br /> OFFIGE USE: I 1. <br /> (For Non-Transterable,Revocable,Suspendable) PUMP&WELL <br /> - I ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY �. ;ri Eli ' I fx- + -% F ' , . <br /> (COMPLETE IN TRIPLICATE) r. - .'� <br /> Application is hereby made to the San Joaquin Local Health District for,a. perrT itto construct and/or install the work herein described.This application is <br /> made in compliance with San-Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> t City/Town <br /> Exac a Address <br /> Phone <br /> Owner's Na a <br /> I irk City S <br /> Address <br /> Contractor's Name ' License#33� Business Phone <br /> #2 sF +�u�f' �,'� Emergency Phone <br /> I Contractor's Address - - No <br /> Is Certificate of Workman's Compensation Insurance on_Rie With SJLHD- Yes D _ <br /> TYPE OF WORK (CHECK): NEW WELL❑' "DEEPEN ❑_ " RECONDITION❑ DESTRUCTION <br /> CHLORINATION ❑ %4ELL ABANDONMENT-0 OTHER ❑ PUMP INSTALLATION �` PUMP REPAIR❑ �y <br /> WELL CHLORIN I ,. <br /> REPLACEMENTD - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sevuage Disposal Field Cesspool/Seepage Pit - Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> ' INTENDED USE j TYPE OF WELL <br /> ❑ I STRIAE � - ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ESS DOMESTIC/PRIVATE � - - - - <br /> ❑ t3 DREN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> [],DISPOSAL q Cl OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Jnstalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR:: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 laws <br /> o which this permit <br /> ! is issued, 1 shall not any person in such manner as to become subject to workman's compensation laws o1 California." <br /> Contractor's hiring orsub-contracting signature certifies the to <br /> ii, certify that in the performance of the work fvrwhich this <br /> permit is issued, I shall employ persons subject to workman's,compensation laws of California." <br /> I will or Groutpl action prior to grouting and a final inspection. <br /> I _ t 1 7—,�.�- - <br /> Signed X - Title: ?I't�V1�-� <br /> i Date: <br /> I` (Draw Plot Plan on Reverse Side) <br /> j Y FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> /.:'o <br /> Application Accepted By <br /> ' - Date <br /> Additional Comments: <br /> ' a finallnspection �` .d^i� <br /> _ Phase ll Grout Inspection +. <br /> Date Inspection By .Date - <br /> I Inspection By `, , <br /> I' s _ <br /> Fee Is Due: ❑ ANNUALLY'. > ❑ PER UNIT"` ❑ PER SITE ❑ EACH - ❑ January 1 R Received By January 31 July 1 &Received By July 31 - <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> a - - "BASE-- ExPLANATION DATE DATE REMITTED AMOUNT <br /> IIM. <br /> T FEE <br /> LESS <br /> PRORATION <br /> � Y <br /> PLUS - <br /> PENALTY. <br /> OTHER <br /> OTHER <br /> 1 - 'I„ —}""raj "€'. " I <br /> Received by <br /> Date -` Receipt No. --� '- Permit No., Issuance Date Mailed Delivered <br /> 01 <br /> APPLICANT—RETURN ALLICOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br /> qii <br />