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perly <br /> Applications Will Be Processed When SubAmPPLICATIONp e -7 <br /> FOR OFFICE USE: <br /> Tl (For Non-Translerable,'Revocabte'Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY °. ,,... el &J <br /> (COMPLETE IN TRIPLICATE) <br /> uin Local Health District fora permit to canstructand/or.install the work,herein described.This application Is <br /> Application is hereby made to the San Joaq <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations af,the San Joaquin Local Health District. <br /> r City/Town <br /> Exact Site Address <br /> Phone 2 <br /> Owner's Name City{ <br /> " �1. <br /> Address ,� Business Phl 1 1 <br /> 1 Contractor's Name � � ��-� - License#' •� "� <br /> �. '� Q Jr Emergency Phone <br /> Contractor's Address �- No <br /> Is Cer,Yificate of Workman's Compensation Insurance on File With SJLHD? Yes � <br /> TYPE OF WORK (CHECK): w NEW WELL-0— DEEPEN❑❑ 'OTHERRECONDITION <br /> ITI P❑P INSTALLATION <br /> f___P_UMP <br /> REPAIR❑ <br /> WELL CHLORINATION-0 WELL ABANDONMENT <br /> REPLACEMENT❑ .. Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> ❑ IN $STRIAE °❑ CABLE TOOL ET Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATEGauge of Casing <br /> ❑ DOMESTIClPUBLIC '�❑ DRIVEN' <br /> ❑ IRRIGATION y}�$ -❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION r <br /> 13 ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information <br /> C Surface Seal Install9d By: <br /> ❑ GEOPHYSICAL <br /> Contractor <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ~ <br /> Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: fi. <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. c <br /> Home owner or licensed agent's signature certitles 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 sof the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> it a Ido a Grout Insp_ tion prior to grouting and a final inspection. :. j <br /> Title: ..E3« �--�- - Date: If <br /> Signed _ <br /> li (Draw Plot Plan on Reverse Side) I <br /> ' r FOR DEPARTMENT USE ONLY <br /> PHASE I 1 `7�� — � ! � Date <br /> j Application Accepted By s <br /> Additional Comments: <br /> " Ph e 1 Final Inspection w/�/ <br /> Phase II Grout Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> ❑ Jarary 1 &Received By Janl 31 C3 July 1 &Received By July 31 <br /> Fee IS Due: C1 ANNUALLY PER UNIT El PER SITE ❑ EACH dREMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> q <br /> FEE <br /> LESS' <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> OTHER _ <br /> .k el No. Issuanc Date.- Mailed Delivered <br /> Received by Date Receipt No. - CA 95201 <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, <br /> r - <br />