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T Applications Will Be Processed When Submitted Properly compleieu.oe aurc r v­v- •••�^rr••�•-• <br /> FOR OFFICE USE: APPLICATION <br /> Nii"(For Non-Transferable,Revocable,Suspendable)`■/ pUMP&WELL <br /> -•''� ' ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 7VI-i c ZSp.-DeG / <br /> (COMPLETE IN TRIPLICATE) sS f.'V. . <br /> Application is hereby made to the San Joaquln Local Hoa ith Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin/;County Ordinancet Ptr 1862 and the rut s and regulations of the San Joaquin Local Health District. <br /> Exact Site Addressf'6 - -C rn City/Town <br /> Phone <br /> Owner's Name <br /> Address ' City <br /> License# Q /3 Business Phone <br /> Contractor's Name <br /> Contractor's Address ��' 9��" �1�� Emergency.Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ '; If <br /> DISTANCE TO NEAREST: Septic Tank —— Sewer Lines Pit Privy <br /> Sewage Disposal Field_ '70'-,'- Cesspool/Seepage Pit Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> r❑ef INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation— <br /> 0 <br /> J <br /> Jcv DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r ❑ IRRIGATION JN <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> r ❑ DISPOSAL_ ❑ OTHER Other Information <br /> 11 Surface Seal Installed Sy: <br /> ❑ GEOPHYSICAL n _ <br /> PUMP INSTALLATION: I Contractor <br /> 1 Type of Pump H.P. I <br /> PUMP REPLACEMENT: 1 ❑ State Work Done <br /> PUMP REPAIR: U ❑ State Work Done <br /> DESTRUCTION OF WELL: { Well Diameter j 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 /> Homeowner 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(o workman's compensation laws of California." <br /> r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." _ <br /> I will all for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: 4 Date: �2 <br /> :l (Dr w Plot Plan on Reverse Side) <br /> t .FOR DEPARTMENT USE ONLY <br /> I <br /> PHASEIS) � A r�� �� <br /> Application Accepted By, /V� a��� Date <br /> Additional Comments: <br /> yyyy��,,s�Ph �,ro�ut�,In✓-spection ��// Phase III Final Inspection <br /> Inspection By1C/ -�� v Date/�� "" Inspection By NI ft Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> ( REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> {{..��,, DATE DATE REMITTED AMOUNT <br /> FEE GW' a 1 ., <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY !< <br /> OTHER <br /> OTHER <br /> la t It )32 <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br /> �.: 0 .. <br />