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Applications Will Be Processed When Submitted Property Completed.Be sure To bign me Application. <br /> F __ <br /> FOR OFFICE USE: Cdr /a APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE WATER QUALITY _d_e,J; <br /> /44ts e_f lEz>g7-"cc.£ �t T <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.1882 and the rules and regulations of the San Joaquin Local Health District. <br /> h Exact Site Address 3 d-_ hi or ib r City/Town " <br /> Owner's Name ePhone <br /> Address w _ City tI!- ,Pit 11rr J <br /> Contractor's Name -� ++ License# r 2-3'-Business Phone t- 7C 74 <br /> Contractor's Address a a- rt1/ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION DESTRUCTION 13 <br /> WELL CHLORINATION..❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 99 <br /> 1 REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field besspool/Seepage Pit Other <br />' Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> F13DOMESTIC/PRIVATE 13DRILLED Dia:of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ZQ 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: W Contractor <br /> Type of Pump at r eSr H.P_ <br /> - __..... <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 /> t , <br /> I. , <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Gounty <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 orsub-cantraeting e11nalur,certlfies the following:"I certify that in the performanceot the work forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp do r grout g and a final InApection. <br /> 111 Signed X itis: / Date: de <br /> (Draw Plo Ian on Reverse Side) <br /> F R ARTMENT USE ONLY ^ <br /> . c <br /> PHASE ? <br /> Application Accepted Da <br /> F, G <br /> i Additional Comments <br /> Phase 11 Grout Inspection Phase III Final Inspection <br />{ Inspection By Date .inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PE9 UNIT ❑ PER SITE ❑ EACM ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> j OTHER <br /> k OTHER <br /> j Recemed by Date Receipt No. Permit No. Assuanch Date Mailed Delivered <br /> jjj^^^ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 200 STOCKTON,CA 95101 <br />