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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicatfoh. f! <br /> FOR OFJCE USE: APPLICATION <br />' <br /> 3=0 (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> C�.•b�: <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .WATER QUALITY . <br /> t:Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or ins tall.the work,hereln described.This application is <br /> made in compliance wit San Joa uin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> ; <br /> ODS.•,,,. r_.. City/Town <br /> Exact Site Address <br /> Owner's Name ' Phone �7 7� <br /> Address :g City lam: <br /> Contractor's Name ' � License.# 7 Business Phone "! <br /> �` <br /> Contractor's Address _jrary 1 g7 '"= =° `' ` Emergency Phone <br /> Is Certificate of Workman's Compensation fnsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK) fNEW WELL,EP'' DEEPEN-13- RECONDITION❑ �'-DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER.11 PUMP INSTALLATION ❑ PUMP REPAIR <br /> 1 REPLACEMENT❑ <br />` DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy '' f <br /> f -Sewage Disposal Field Cesspool/Seepage Pit Other- r ' <br /> r Property Line Private Domestic Well Public Domestic.Well -F.,. .y <br /> ► INTENDED USE TYPE OF WELL ' LU <br /> ❑•INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' fj . ; <br /> ❑ IRRIGATION (] GRAVEL PACK Depth of Grout Seal A <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL. Surface.Seal Installed By: <br /> 77 <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump ` H.P. <br /> .PUMP REPLACEMENT: � State Work Done <br /> i PUMP REPAIR: CI-State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F Describe Material and Procedure ti <br /> I hereby certify that l'have prepared this application and that the work will be done in accordance with San Joaquin County 4 <br /> ordinances, state laws, and rules and regulations of the San.Joaquin Local Health District. <br /> Home owner or licensed agent's isignature certifies the following"I certify that in the performance of the work for which this permit <br /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Q <br /> a Contractor's hiring or sub-contracting signature certifies the fallowing:"'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 /> 1 will call for Grout Inspection prior to grouting and a final inspection. <br /> Signed X-A�+;b yY1__ r 1 �f ��•._.Title: - Date: <br /> 3 (Draw Plot Plan on Reversely de) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE — . <br /> Application-Accepted By s LJ Date k <br /> ag27&L r Additional Comments: j <br /> - Phase II Grout Inspection Phase fl Final Inspection <br /> f Inspection By Date Inspection By Date <br /> • Fee Is Due: ❑ ANNUALLY t ❑,PERF NIT ❑ PER SITE EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> { REMIT <br /> -' <br /> -BASE EXPLANATION 'BILLING. REMITTANCE - $ AMOUNT DUE CHECKED - <br /> gyp' DATE DATE, REMITTED AMOUNT , <br /> FEE A A <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> - - ,- – <br /> OTHER <br /> Received by Date Receipt No- Permit Na. issuance Date Mailed. Delivered <br /> t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,CA 95201 <br />