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Applications Will Be ProcessedWhen suornmearropenya.vmpluavu. o� �u � •��••n -rr- <br /> FOR gFFICE USE: APPLICATION <br /> s (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r- <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 with S y C Joaquin t Ord' c 18 a d the rules and regulations of the San yJ a u'.nJ_� ealth District. <br /> Exact Site Address q /J / � yCity/Town <br /> Owner's Na V —e-Z(/�� �R5 / • C%Q � Phone <br /> Address City <br /> -- . .. _. <br /> Contractor's Nam License# Business Phone. <br /> Contractor's-Address d v _ __ Emergency Ph a _,�� <br /> M1 fo. .ut <br /> Is Certificate of Workman's Co pAa, I r� ranee on File With SJ LH D? Yes No <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL A ANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11Z-7—,-D �� <br /> DISTANCE TO NEAREST: Septic Tank "'t Sewer Lines�`� Pit Pri`vy/ <br /> Sewage Disposal Field Cesspogl/Seepage Pit �/ �ther <br /> Property Line__Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> at•- <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing S <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> T_ <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. G <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: i Well Diameter I 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. 'L. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work far 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 P91sons subject to workman's compensation laws of California." <br /> 1 will for Grou spect' rior to grouting and a final inspe n ` <br /> Signed X -- <br /> Title: i���'� Date: e:�—a' <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Date <br /> Application Q <br /> Application Accepted By / / t <br /> Additional Comments: J U <br /> Phase ou nspectio "' Phase III Final Inspection <br /> Inspection B ' ��z'^� Date <br /> Irtspectton By <br /> Feels Due. ❑ ANNUALLY ❑ PE UNIT ❑ PER SITE,-, ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 3 �°_' <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d <br /> la t3/� 4 <br /> Received by Date Receipt No. Permit No. Issuance Dath Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />