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Applications Will Be Processed When Submitted Properly"Completed. Be Sure To Sign The Application. -- <br /> 1 <br /> FOR OFFICE USE: <br /> -i APPLICATION <br /> t <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL ; If <br /> (COMPLETE IN TRIPLICATE)a�s C07WATER QUALITY T-455" 1� <br /> V <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.-This application is ; <br /> made in compliance with San Joaquin Co my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site AddressL!� City/Town <br /> orl <br /> Owner's Name <br /> Phone_.'334-- <br /> Address <br /> 34—Address <br /> Contractor's Name License# 7 Bus - <br /> �� Business Ph e <br /> Contractor's Address c <br /> iM 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❑ # <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines'AJ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other + <br /> Y <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia, of Well Excavation <br /> .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing S <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �! t <br /> 13 IRRIGATION El GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> El DISPOSAL ❑ OTHER Other Information P <br /> ❑ GEOPHYSICAL Surface eal I stalled By: 3 <br /> jjjContractor— <br /> Type <br /> C t <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump }L H P <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: 13 State Work Done <br /> }DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> !j Describe Material and Procedure <br /> I hereby certify that j`have prepared-this`application-and that-the-work'will'be`done in accordance with San-Joaquin-County A <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 o!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 corr`pensation laws of California." <br /> Contractor's hiring orsub-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."s <br /> I ca a Grout Inspection prior to grouting and a final inspection. 1 <br /> r <br /> Signe jTitle: -LWt.r� w. ! Date: <br /> (Draw Plot Plan on Reverse Side) f; <br /> I! FOR DEPARTMENT`USE'ONLY i <br /> PHASE I <br /> Application Accepted By <br /> Date <br /> Additional Comments: f I <br /> Phase II Grout Inspection Phase. I I nspection rr Q <br /> Inspection By Date Inspection By Date The <br /> Fee Is Due: ❑ ANNUALLY PER UNIT 111 <br /> " � PER SITE El ❑ January 1 Received By January 31 El 1 &Received By July 31 BILLING F <br /> REMITTANCE REMIT <br /> BASE EXPLANATION $ i AMOUNT DUE CHECKED <br /> { GATE DATE REMITTED AMOUNT <br /> } <br /> FEE t m� 1 � , c� <br /> LESS s <br /> PRORATION A <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ... '] <br /> Received by Oate Receipt No Permit-No. Issuance Date Mailed Deliv d - 7: <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTO ,CA 952 /t <br />