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t <br /> Applications Will Be Processed When uAPPLICATION <br /> , OR_Or,FiCE USE: 'r (For Non-Transferable, Revocable,Suspenda e) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> WATER QUALITY application is i <br /> (COMPLETE IN TRIPLICATE) <br /> 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Application is hereby made to the San Joaquin Local Health l7isirictfora permitto construct and <br /> install the work herein described. Is <br /> Ap¢ • <br /> made in compliance with San Joaquin County Ord.na ce N City/Town <br /> Exact Site Address Phone <br /> Owner's Name City s � <br /> Address ' icense# � — Business Phone <br /> l <br /> Contractor's Name Emergency Phone <br /> No <br />'i. Contractor's Addressart <br /> ;s Certificate of Workman s Compe sab n Insuran DEEPEN With SRECONDITION A DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL❑ <br /> li PUMP INSTALLATION❑ PUMP REPAIR <br /> WELL CHLORINATION C3WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ Pit Privy <br />` DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> v Property Line Private Domestic Well <br /> TYPE OF WELL <br /> 1 INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Wel; Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION k Other Information C3DISPOSAL El OTHER Surface Sea; Installed By: <br /> ❑ GEOPHYSICAL <br /> iContractor H,P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: _ y State Work Done <br /> PUMP REPAIR: Approx' ate Dept <br /> OF WELL: <br /> Well Diameter , V <br /> Describe Material and Pr edure <br /> t <br /> y— <br /> ared t application and that the work'wi41 be done accordance with San Joaquin County <br /> 04F.J6W Wreby ertify that I have prep <br /> ordinances, state laws, and rules and regulations of the San JoagCeLO thlatintheperformanceoftheworkforwhichthispermit <br /> Home owner or licensed agent's signature certifies the following:" Y <br /> f 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 orsub-contracting signature certifies the following:"I certify that in the performance of the avork for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of CaUforn;ay' Y r <br /> I will 01-for a Grout Ins tion riolto grouting and a final inspection. Dale: W. <br /> o <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY 7 <br /> Date <br /> r PHASE - <br /> 7 <br /> I Application Accepted By 6 <br /> Additional Comments. a III Final Inspection <br /> ase-II r t Inspection t .� Date <br /> Inspection By <br /> Date � Inspection lay <br /> 1&-Received By January 31 ❑ July 1 &Received By July 31 <br /> } REMIT <br /> r Fee Is Due'. ❑ ANNUALLY CJ UNIT � PER SITE ❑ EACH Sanuary CHECKED <br /> BILLING REMITTANCE $ AMOUNT DUE <br /> EASE EXPLANATION PATE <br /> DATE REMITTED AMOUNT <br /> q[ <br /> FEE <br /> LESS <br /> r.- PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> � OTHER <br /> 30� <br /> N . Permit No- <br /> Receipt o15suan a Date Mailed Detivered <br /> ^�- �� �Date - � <br /> APPLICANT—RETURN ALL COME 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,GA 95267 <br /> Received ey <br /> S TO: ENVIRONMENTAL HEALTH pERMIT/SERVICES <br />