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ca ions Will Be Processed u rru e <br /> _ v—'W" ••• -rr <br /> FOR OFFICE USE: 11l t 1 1980 APPLICATION <br /> �J U L (For Non-Transterable, Revocable, Suspendable) PUMP&WELL <br /> AN ,�OAQ� I� <br /> I I RONMENTAL HEALTH PERMIT <br /> S <br /> (COMPLETE IN TRIPLICATENEAL-TH <br /> DISTRICT WATER QUALITY <br /> Ai3plication 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 /> made in compliance witlSl in County Ordinance No.1862 and the rules and regulations of the San Jo +in Local Health District. <br /> Exact Site Address City/Town <br /> 0I-r.110 Phone <br /> Owner's Name <br /> Address City <br /> Address <br /> License#37o Business Phone aS] <br /> Contractor's Name Phone <br /> Contractor's Address Emergency Phone <br /> 4 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ .J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> 1� 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 Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 4`1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 1 <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call a Grout Inspect' p ' r to grouting and a final InspectiII <br /> Signed X � ,r� .— Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPART ENT USE ONLY <br /> PHASE 1 � <br /> Application Accepted By r Date <br /> Additional Comments: <br /> Phase It Grout Inspection /Ph a III Final Inspection <br /> Inspection By Date inspection By/ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT L3 PEH SITE ❑ EACH ❑ January 1 R Received By January 3 �i❑t'JtAuly 1 &ReceiveRdEMIBy Tuly 31 <br /> SE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0,7-3)1 <br /> +�lYd <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />