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Applications Will Be 40cessed When Submitted Properly Completed.Besure 1o*19n 1nenyF.++vp.•••••• <br /> FOR OFFICE USE: APPLICATION <br /> All! <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> irilLocal Health District for a permit to construct and/or install the work,herein described.This appl <br /> Application is hereby made to the San Joaquication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules"and regulations iy/7ownthe san Joaquin Local Health District. <br /> Exact Site Address <br /> Phone s <br /> Owner's Name G City . J <br /> Address Business Phone_ license#�� <br /> Contractor's Name Emergency Phone I <br /> �Do .s: le�� No O <br /> Contractor's Address �' <br /> Is Gertificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL- 0 <br /> 13RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑• WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION E] PUMP REPAIR❑ <br /> REPLACEMENT❑ ��` '"� _ Pit Privy - _ u <br /> it �- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines t Other <br /> Sewage Dip.6sal Field I � '7�`— Cesspool/Seepage Pity' <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE <br /> I TYPE OF WELL Al <br /> Dia. of Well Excavation <br /> l <br /> C1 INDUSTRIAL <br /> - ❑ CABLE TOOL i. <br /> b.DRILLED Dia. of Well Casing <br /> OMESTIClPRIVATE' `. .. . _ DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC Depth of Grout Seal <br /> 1-1IRRIGATION <br /> t RAVEL PACK <br /> 11 CATHODIC PROTECTION � OTARY....--, - 4 Type of Grout <br /> ❑ DISPOSAL I� OTHER iOther Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: jF ontractor <br /> H.P. <br /> jype of PUMP <br /> El State Work Done <br /> PUMP REPLACEMENT: �• <br /> PUMP REPAIR: ❑ State Work Done <br /> � <br /> DESTRUCTION OF WELL: 'Well Diameter + Approximate Depth C <br /> Describe Material and Procedure <br /> i l <br /> 1 hereby certify that I have prepared this application and thatlthe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rubes 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 /> anct to workman's compensation laws of California." <br /> is issued, i shall not employy person in such manner as to become subje <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this Q <br /> permit is issue , I shall employ persons subject to workman's compensation laws of California." <br /> I wil call or Grout Inspection prior to grouting and-9 final inspection. <br /> Title: Date: 1 <br /> Signed X (Draw Plot Pian'on Reverse Side) l <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: Phase tll Final Inspection <br /> FPh lout Insfsectlan N <br /> Inspection By <br /> ate /`" -I - - Inspection By _ �� Date <br /> Fee IS Due: El ANNUALLY ❑ P NIT P R SITE EACH J n y 1 &Received By January 31 ❑ July 1 ReceivedREMIT <br /> d By July 31 <br /> * _ NG REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANAT�O DATE <br /> DATE REMITTED AMDUNT <br /> Qy �;ii T / I - �LA3 <br /> FEE ( , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date ` Receipt No. Permit No.. <br /> is uance D e Mailed Delivered <br /> Received by 1601 E. AZELTON AVE.,P.O.Bon 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITlSERVICES <br />