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Applications Will Be Processed When Submitted Properly Completed.Besere Ioatgn�nvv-•, f <br /> - fit APPLICATION <br /> FOR OFFICE USE: <br /> � t (For Non-Transferable, Revocable, Suspendab ) PUMP 1�1 <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> WATER QUALITY <br /> ribei ,(COMPLETE IN TRIPLICATE) <br /> F <br /> Application is hereby madetotheSanJoaquin LocalhNo. 1862 and District fora tthe ides and regulations s oftthe <br /> San JoaquinlLocalcHealdth application is J <br /> made in compliance with San Joaquin County ordinance/ City/Town <br /> G <br /> I' Exact Site Address <br /> O Phone <br /> Owner's Name ` City ! <br /> Address <br /> L'+cense# 2 JO Business Phone 4 "S <br /> Contractor's Name �O <br /> / �( .� n Emerg ericy Phone .l <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation.Insurance on File With SRECONDITION 13DESTRUCTI N <br /> tp <br /> i TYPE OF WORK (CHECK): NEW WELL`@/ DEEPEN <br /> i <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION^ PUMP REPAIR❑ <br /> E � <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal FieldticDomestic Well <br /> Property Line jam— Private Domestic Well <br /> INTENDED USE TYPE OF WELL �J <br /> 13 CABLE TOOL Dia. of 1(Vel1 Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> i 11DOMESTIC/PRIVATE <br /> 13 DRILLED i <br /> ❑ DRIVEN Gauge of Casing <br /> f IX DOMESTIC/PUBLIC Depth of Grout Sear CJ , <br /> C3 IRRIGATION 13 GRAVEL PACK p r <br /> ❑ ROTARY Type of Grout ••^� •,-_ <br /> ❑ CATHODIC PROTECTION Other Information �- <br /> 13 DISPOSAL 1:1 OTHER <br /> XJ <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> t Type of Pump <br /> State Work Done <br /> PUMP REPLACEMENT: ❑ <br /> ❑ State Work Done <br /> PUMP REPAIR: <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> i <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 /> 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 will call for a Grout In5pection prior to grouting and a final inspection. <br /> � © <br /> _ Date: <br /> Title: <br /> Signed X (Draw Plat Plan on Reverse Side) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I ate C �� <br /> Application Accepted By f <br /> Additional Comments: i✓�t�w <br /> h Ili Final Inspection � <br /> Phase Inspection ate <br /> Inspection By <br /> Date — Inspection B <br /> r+o�^ Jut' 1 &Received By July 31 <br /> Fee is Due. El ANNUALLY ❑ PER UNIT L6 PER SITE ❑ EACH ❑ January 1 &Received By January 3 y REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> 1 LESS <br /> PRORATION <br /> s PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 <br /> K �� Issuance Date Mailed Delivered <br /> Receipt No. Permit No. <br /> - Received by Date 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 85201 <br /> —,RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITl5ERYICES <br />