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r Applications'Will Be Processed When Submlltea vropeny L.omplelea. nwu 01y+- ^rr �� �•�1� <br /> 'FOR.OFFICE USE: APPLICATION �g8� <br /> (For Non-Transferable, Revocable, Suspen aP1.) �U G <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , , t O%CAL <br /> �-� SAN JDF,i��fRl <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i �A' -TH DISTRICT <br /> I <br /> Application is hereby made to the San Joaquin Local Health Districtlora permit to construct and/or instaework herein described.This application is <br /> made in compliance with San Joa ui County Ordinance No- 62 and the rules and regulations of the San�Jo�a,quin ocalHealth District. <br /> Exact Site Address r �� CitylTown �•_�� <br /> " �A _ <br /> Owner's Name Phone <br /> Address � ,"fie- � City <br /> �! -- - i <br /> Contractor's Name ->( ik r se License# Business Phone_ <br /> 1 Emergency Phone -- S <br /> Contractor's Address C <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes N) No — _ <br /> TYPE OF WORK (CHECK): NEW WELL C1 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 Other <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 C <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 9 State Work Done s <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <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 l <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit N <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractors 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 /> I wil II for a G�nsn prior to grouting and a final Inspec Title: Date: <br /> Signed X , <br /> (Draw Plot Plan on Reverse Side) <br /> FO SPAR ENT USE ONLY ` <br /> PHASE I I S U� <br /> Application Accepted By - 4 --- Date - <br /> Additional Comments: - <br /> 4Phase II Grout Inspection ase III Finsi Inspection ' <br /> Inspection By Date inspection By Date` ' <br /> Fee Is Due: ElANNUALt Y ❑ PER UNIT PER SIT E ❑ EACH El January 1 &R erved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE — <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s B� 3 0 <br /> Receivetl by Da a Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />