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Applications Will Be Processed When Submitted Properly compleiea. aeaure IU 01911 r,..�+rr• 1 <br /> FOR C"FFICE USE:. ; - <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> e <br /> ENVIRONMENTAL HEALTH PERMIT 4 ' <br /> WATER QUALITY <br /> (COMPLETEJN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to 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 ocal Health District. ' <br /> Exact Site Address —�,..'S�b��� 9-'� City/Town <br /> Owner's Name Phone i <br /> Address City _ J <br /> Contractor's Name License#����QZZ:3 Business Phone <br /> Contractor's Address <br /> Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation.Insurance on File With SJLHD? Yes IO <br /> TYPE OF WORK (CHECK): NEW WEL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 ZZ <br /> �i <br /> ❑,_,,�INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ED DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ gRIVEN Gauge of Casing w� <br /> ❑ IRRIGATION [� RAVEL PACK Depth of Grout Seal S� <br /> ❑ CATHODIC PROTECTION P ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I Ellcall for a Grout In pec ' prior to grouting and a final Inspection. <br /> Signed X Title: Date: 0�7' <br /> (Dra Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g. - <br /> Application Accepted By Date <br /> Additional Comments: " c <br /> Phase 11 Grout Inspection __Ph9'5qAllFijaaI Inspection <br /> Inspection By Date Inspection By 10,6 Date /x <br /> Fee IS Due: ❑ ANNUA PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE LANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> g �9 <br /> AMOUNT <br /> FEEcFt <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r- <br /> OTHER <br /> r <br /> OTHER <br /> If E D ! <br /> Received by bate t. 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 />