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Applications Will Be Processed when SuIAPPL`CArTI ONp e e e of <br /> re7 -2- <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i WATER QUALITY. ._ .,. r-, <br /> (COMPLETE IN TRIPLICATE) P application is <br /> f Application is hereby madetotheSanJoaqukinLocal Health Districtfora ermittoconstructand/orinft.he San Jo herein described.h Dis app' <br /> made in compliance with San�JgAqutin County.Ordinancf eylo.862 and tl�e.rules and regulations of the San Joaquin Local Health District. <br /> i <br /> s Exact Site <br /> f/ C.J CG ,.t ,� .ts� City/Town <br /> Phorie <br /> Owner's Name Clty � - <br /> Address _ ,.r,•--r-.. <br /> License� � Business Phone <br /> Contractor's Name V ' <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r _ <br /> TYPE OF WORK(CFiEC4():__NEW WELL❑ �❑ OTHER <br /> O�171 P OP INSTALLATION Nom" i'UMP REPAIR <br /> WELL CHLORINATION,❑ .7 WELL ABANDONMENT <br /> REPLACEMENT[] _a <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> IG <br /> TYPE OF WELL <br /> INTENDED USE <br /> ❑ i STRIAL ! 13 CABLE TOOL Dia. of Well Excavation- <br /> i ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 1 ❑ DRIVEN <br /> C1 IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> : ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> , t- Su�rf_a-ce Seal In,talled By: . <br /> ' ❑ GEOPHYSICAL -r <br /> L5 211 <br /> PUMP INSTALLATION: Contractor <br /> .. ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR. ❑ State Work Done . <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> P 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 /> F ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certifies the following:"I certify that it the performanceof <br /> compenhe sation <br /> 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 or sub.-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." , <br /> I r- Grout inspectio.n prior to grouting and a final inspection. v <br /> . Title: r� Q/.�— ..- Date: 2 <br /> Signed U r <br /> (Draw Plot Plan on Reverse Side) <br /> t[ FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted 6y <br /> Additional Comments: y� <br /> Phase II Grout Inspection pha ;nInspectionDate <br /> Inspection By .. <br /> `Date Inspection B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE D EACH January 1 &Received By January 31 July 1 &Received By July 3t <br /> ❑- <br /> REMIT <br /> 'BILLING REMITTANCE $- AMOUNT DUE CHECKED <br /> BASE i. EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE{ - - <br /> LESS <br /> PRORATION _ <br /> f� PLUS - <br /> PENALTY' - <br /> OTHER <br /> OTHER - <br /> ;231 j <br /> Received by Date <br /> Receipt No.' - Perms[No - ssuance Date- Mailed' -.. Deli�eretl - <br /> _ 1601 E.HAZEL <br /> AVE.,P.O.Bot 2009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT}SERVICES f <br />