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r �J....r_ _ <br /> Ap�catlons Will Be Process <br /> ed When Submitted properly_ <br /> APPLTCATI N s <br /> iR ocE use:.,- PUMP&WELLXZ, <br /> (Far Non-Transferable,Revocable, �uspendable) j <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY ` <br /> (COMPLETE IN TRIPLICATE) tct <br /> Application is hereby made to the San Joaquin Local <br /> Health <br /> No. 1862 andtrict for a permit ruleco nd`regulatdlons oftthe San Joaquin)LocalcHealdthTDistrhis ict. alio is ' <br /> made in compliance with San Joaquin County O n_ City/Town <br /> Exact Site Address Ih --C - C2T� <br /> Phone <br /> Owner's Name Cit I <br /> AddressLicense#,J_�d Business Phone <br /> 4(0 <br /> Contractor's Name - 1 <br /> 5pr <br /> Contractor's Address ��--- to Emergency Phone No - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes STRUCTION❑ t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN C3 RECONDITION i <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER El PUMP INSTALLATION ❑ PUMP REPAIR l <br /> REPLACEMENT❑ Pit Priv <br /> Sewer Lines y <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well A <br /> INTENDED USE TYPE OF WELL ' <br /> 11 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br />[ ❑ DRILLED Dia. of Well Casing Q <br /> ❑ DOMESTIC/PRIVATE Gauge of Casing fi <br /> 11 DOMESTIC/PUBLIC 11 DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> e IRRIGATION ❑ Type of Grout <br /> 11 CATHODIC CATHODIC PROTECTION A <br /> [3 DISPOSAL <br /> OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Inst Iled B <br /> � :r}�H <br /> PUMP INSTALLATION: Contractor <br /> .P. <br /> Type of Pump <br /> 1 PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> f <br /> Describe Material and Procedure 3 <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. <br /> hich this orw <br /> Home owner or licensed agent' signature n such manneries the certifasto become subject to workman's n's compensay that in the performance of tionrk laws laws of California."lt <br /> is issued, I shall not employ y p 1 <br /> 4 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 shall employ pers Sub' t to rkman's compensation laws of California." <br /> Iwvill lo a Grout Inspectio r to outin d a final inspection. <br /> Date: <br /> Title: <br /> Signed (Draw Plot Plan on Reverse Side) <br /> F F <br /> RD ARTM NT USE ONLY <br /> ` PHASE I Q Date 7� <br /> Application Accepted By <br /> Additional Comments: Phase Final Ins ection <br /> Phase II Grout Inspection ate <br /> Date Inspection ByW <br /> Inspection By � <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DAT •�'; DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> ' PRORATION <br /> f <br /> PLUS <br /> PENALTY <br /> 4 OTHER <br /> f OTHERc!N �.. <br /> �. <br /> — } Mailed Delivered -- <br /> A Received by Date Receipt No. <br /> Permil No Issuance ate <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1607 E.HAZELTON AVE.,P.O.BOX 2609 STOCKTON,GA 9520 <br />