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FOR:OFFICEJ ... ....... �,. ..c... I w�/Q.., ...,...M.z.�,,. ..� •/MI 1...,lea I IIC,. <br /> APPLICATION <br /> t "(For Non Transferable, Revocable,Suspendable <br /> W ENVIRONMN SAL HEALTH PERMIT PUMP&WELL vow <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 0 <br /> ` Application is hereby made.tothe San.Joaquin Local Health Districtfora ermlt-to construct and/orinstalltheQrkr Inmade In compliance with San Joaquin County Ordinance No 1882 andpther.ru es ands "tilations of the Sa <br /> �+ s application is <br /> Exact Site Address. u exit istrict.. <br /> City/Town <br /> Owners Name " <br /> Address Phone. <br /> Contractor's Name fire City <br /> Contractor's Address + License.# ,4Z Business'Phone -- <br /> Is Certificate of Workman's Compensation Emergency Phone <br /> In File With.SJLHD? . ,Yes <br /> TYPE OF 'WORK (CHECK). NEW WELD DEEPEN ❑ No <br /> WELL CHLORINATION ❑ RECONDITION❑ DESTRUCTIONS <br /> WELL ABANDONMENT ❑ OTHER ❑ 'PUMP INSTALLATION❑ Y <br /> REPLACEMENT❑ PUMP R AI <br /> DISTANCE TO NEAREST: Septic Tank Flo. <br /> ' <br /> Sewer Lines ' 1 Pit Privy — - <br /> Sewage Disposal.Field cT ai Cesspooi/Seepage Pit -� <br /> Property Line_1ci"t PrivtDG Other, <br /> INTENDED USE ae omestic Well �' — Public Domestic Well - + <br /> INDUSTRIAL TYPE OF WELL . <br /> ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE 12 <br /> Dia:of Weil Excavation y <br /> DRILLED ' <br /> DOMESTIC/PUBLIC Dia. of Well Casing <br /> ❑ �.DRIVEN <br /> ❑.IRRIGATION Gauge of Casing f <br /> ❑ CGRAVEL PACK Depth of Grout Seal f <br /> ATHODIC PROTECTION ® ROTARY <br /> ❑ DISPOSAL ❑ OTHER Type of Grout p- 11 <br /> ❑ GEOPHYSICAL Other Information -.a~ <br /> PUMP-INSTALLATION:. Surface Seal Installed 8y: <br /> Cafar f� <br /> ontractor <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> ❑:state Work Done <br /> PUMP REPAIR: ❑ 3tate-Work Done <br /> DESTRUCTION'OF WELL: VilellDiamefer <br /> Describe Material and Procedure Approximate.Depth ' <br /> I' <br /> I hereby certify that I have prepared this application and that the work:wiil be done-in accordance with Sall Joaquin County f <br /> i 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:"1 certify that Irl the performance of the work for which this'permit_ <br /> is issued, I shall not em to an <br /> P Y Y person`in such manner as to become Subject to workman's corripensatiornlaws of Cali#,irnla." .' <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this 1 <br /> Permit is issued, I shall employ persons subject to workman's compensation laws of California."' <br /> i will'.call for a Grout lnspectlon prlor- routing and a final inspection. j <br /> Signed X <br /> Title: <br /> (Draw Plot Plan on Reverse Side) Date: <br /> PHASE 1 <br /> FO DEP RTMENT SE ONLY <br /> - , <br /> Application Accepted By ',,. <br /> Additional Comments: bate q �� <br /> Phase II Grout Inspection <br /> Inspection By6� P se Itl Final Inspection <br /> Date <br /> ~ Inspection By nate <br /> Fee'IS DUe: ❑ ANNUALLY ❑ PER UNIT PER SITE I] EACH <br /> ❑ 'January 1&Received.By January 31 ❑ July 1 &Received 8y July T31 <br /> BASE EXPLANATION BILLING REMITTANCE $ PAN <br /> DATE DATE REMITTED AMOUNT DUE <br /> FEE' <br /> LESSPRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DateReceipt No: 91�$ Z <br /> Permit No. ' Issuance Da e �Mailed Delivered. <br /> APPLICANT—RETURN.ALL-COPIES TO:- ENVIRONMENTAL HEALTH PERMITISERVICES - <br /> 1661 E.HAZELTON.AYE.;.P.O.Boit 2009 'STOCKTON,CA`95201.`-' , <br />