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L Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f <br /> FOR OFFICE USE: r APPLICATION <br /> _y .0 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENT'AI MEAL.TH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work-herein described.This application is <br /> made in compliance with an oaq in u ty O inance N 186 nd the, rules regulations of the San Joaquin Local,Health District. <br /> Exact Site Address .a City/Town <br /> Owner`s Name ',ar' "`n'- Phone 1 <br /> Address ®' �" ° City <br /> Contractor's Name - r License#In Business Phone <br /> Alp � .. <br /> I <br /> Contractor's Address p'x -"Emergency Phone ; t:' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE'OF WORK (CHECK): EW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑' <br /> WELL CHLORINATION ❑- WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑�. PUMP REPAIR <br /> REPLACEMENT❑: <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit t1 Other <br /> Property Line Private Domestic Well Public Domestic,Well <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL .Z ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED_ Dia. of Well Casing <br /> t ❑ DOMESTIC/PUBLIC 0DRIVEN Gauge of Casing <br /> 9 g j <br /> '� <br /> ❑ IRRIGATION "- ElGRAVEL PA6 <br /> M1K Depth of Grout Seal { <br /> ❑ CATHODIC PROTECTION w ❑ ROTARY Type of Grout <br /> 1:1 DISPOSAL ❑"C+}THER Other Information <br /> ❑ GEOPHYSICAL -k Surface Seal Installed By: a <br /> PUMP INSTALLATION: Contractor t <br /> 1 Type�f Pump 1 1 H?P. . <br /> PUMP REPLACEMENT: ❑-State WorkDone'- <br /> PUMP REPAIR: State Work DOFie <br /> I DESTRUCTION OF WELL: Well-Diameter Approxi ateDepth <br /> ,Describe_Material-and_P..rocedureri--�------­ - -- - <br /> t I hereby certify that I have prepared this application and that the work"will be one in accordance with San Joaquin County <br /> 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:"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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> !INIII call for a Grou Inspection prior to grouting and a final in2eveme"Side) <br /> tio . '^ <br /> Signed X Title: " Date:_ r 2' s Ll <br /> (Draw Plot Plan on <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By f ` -- Date <br /> Additional Comments: <br /> Phase II Grout Inspection as Inal Inspection,,/ <br /> Inspection By - t Date" Inspection By PhDate / <br /> °t Fee Is Due: 11ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i f <br /> REMIT- <br /> iBILLING REMITTANCE - $ AMOUNT-DUE CHECKED <br /> ' BASE EXPLANATION' DATE DATE REMITTED - <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION a <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER r # t <br /> r F t <br /> Received by - Date Receipt NoPermit No._i_ -- .—Iss Nance"D to -: Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />