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alltU <br /> Applications Will Be Processed.When Submitted Properlycompiezea. <br /> APPLICATION <br /> FOR OFFICE USE: i <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL € <br /> -�" ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application Is ! <br /> made in compliance S J q ty Ord' c No. 1862-And the rules and regulations of the San aquuIn L�ocal <br /> althrDi i ` <br /> �� ��y City/Town <br /> Exact Site Address �_ r <br /> Phone � � <br /> `1 <br /> Owner's Name City -- <br /> Address Bu iness Phone f i <br /> Contractor's Nam en y Phone <br /> Contractor's Address ?/ Yes eC,�- No <br /> Is Certificate of Workman's Compensation Insurance on ile Wi h JLH vVh <br /> TYPE OF WORK (CHECK): EW � E0❑ ORECONDITIONDESTRUCTION <br /> OTHER0P INSTALLATION REPAIR <br /> WELL CHLORINATION ElNEW <br /> ABANMNT <br /> I <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tan Sewer Lines y <br /> Cesspool/Seepage <br /> Pit Other—,— <br /> 'K <br /> Sewage Disposal Fie cl S <br /> Property LineItf Private Domestic WellPublic Domestic Well <br /> INTENDED OF WELL <br /> USE <br /> ❑ <br /> ❑ I STRIAL CABLE TOOL Dia. of Well Excavation � <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION ❑��GRAV� EL PACK Depth of Grout Seal <br /> I Lp1"ROTARY Type of Grout <br /> 4 <br /> El CATHODIC PROTECTION Other Information <br /> El DISPOSAL <br /> 13 OTHER { P 5 <br />! Surface Seal installed By: <br /> 11 GEOPHYSICAL <br /> III PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: l <br /> ,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 /> 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:"l certify that in the performance of the work for which this permit <br /> become subject to workman' <br /> is issued, I shall not employ any person in such manner as to s compensation laws of California." <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the per <br /> of the work for which this <br /> l permit is issued, i shall m p ons subject to workman's compensation laws of California." <br /> 4 <br /> I ill call for a Gro t e io prior o r ting and a final inspection. <br /> j Title,` '� _ Date: <br /> (Draw Plot Plan on Reverse Side) ` <br /> f FOR DEPARTMENT USE ONLY <br /> Date <br /> t Application Accepted By <br /> Additional Comments: zr� <br /> inal Inspection <br /> Phase!I Grout Inspection ` Date <br /> Inspection B <br /> Date Inspection By <br /> ` ER UNIT ❑ PER SITE El EACH ❑-January 1 &Received By January 31 ElJuiy 1 &ReceivedByJuly 31 <br /> Fee IS DUe: ❑ ANNUALLY 0 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Q1 <br /> FEE <br /> i <br /> pk LESS <br /> F PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Date <br /> opt Na. Permit No <br /> Received by ec <br /> , Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 16Q1 E.HAZELTON AVE..P.O:Boz 2009 STOCKTON,CA 9520 <br />