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Applications Will Be Processed When submitted Properly Completed.Be Sure <br /> Faa OFFICEuse: APPLICATION - <br /> (For Non-Transferable, Revdcable,Suspendable) PUMP&WELL <br /> Y- ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY,, <br /> _ (COMPLETE IN TRIPLICATE) k This r�itto construct <br /> Application is hereby made to the San Joaquin Local HealthDisdphe rulesandregulattiiionsofthe S nJoaquin herein <br /> �ocalcHealltthDistric�kicationis <br /> made in-compliance with San Joaqui ]862an <br /> County Ordinance No, v City/Town <br /> Exact Site Address^ <br /> " v . C; t Phone <br /> Owner's Name ' <br /> � � � �.� ,. City <br /> Address *t r. ' wr Business Phone k <br /> �- s 4' Llcerrse# <br /> f Contractor's NamePhZ <br /> t: l...: GY p y Emergency one <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes m-- <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ OTHER O❑ ITI PUMP <br /> INSTALLATION PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> REPLACEMENT❑ / Sewer Lines Pit Privy _ <br /> DISTANCE TO NEAREST: Septic Tank - •--�•� Other <br /> Sewage Disposal Field Cesspool/Seepage'Pit` <br /> r te Domestic Well Public Domestic Well <br /> Property Line Priva <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> 13DRILLED Dia. of Well Casing <br /> ❑ DOMEINDUS TIC/PRIVATE <br /> 1:1 DOMESTIC/PUBLIC 1-3DRIVEN Gauge of Casing <br /> ❑ GRAVEL_PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION 11 ROTARY _ > G <br /> ' ❑ OTHER Other Informatioh fi <br /> ❑ DISPOSAL Surface Seal Installed By:. >J s <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUhi4 __ ❑ State Work Done <br /> Well Diameter « Appro imat Depth <br /> ES7RUCTION OF WELL: s <br /> Describe Material and Procedur <br /> ti <br /> ?" i hereby certify that k have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . <br /> Home owner orllcensed agent's signature certifies the following:"I certify that in the perfo;rmanceof the work for which this permit i <br /> is issued, i shall not employ any person in such manner as to become subject to-workrrian's'compensation laws of California." t <br /> Contractor's hiring or.,sub-con signature certifies the foklowing:"l certify that in the performance of the work Lorwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will IpA for a Groutdns eciion prior to grouting and a final inspection. w+ "/�jR�•. ' t�"� <br /> f �`"_` Title: Date ��+ �- <br /> [, <br /> Sign l;d X <br /> (Draw Plot Plan on Reverse Side) <br /> + <br /> a FOR DEPARTMENT USE ONLY <br /> PHASE I '( Date <br /> Application Accepted By— <br /> Additional Comments ` r ase it, Feciion <br /> Phase It Grout Inspection e P <br /> Inspection By. <br /> Inspection By- <br /> Inspection <br /> '" ' '8 tPER UNIT ❑,PER SITE -❑ EACH, ❑ January i &Received By-January 31 ❑ July 1 8 Receiv REIT <br /> 31' <br /> Fee IS Due: ❑ ANNUALLY ❑ <br /> 'BILLING- -REMITTANCE - $` - AMOUNT DUE CHECKED <br /> BASE'`F' EXPLANATION DATE DATE -REMITTED: AMOUNT <br /> FEE lJ - <br /> .:i LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER~ ? ._• ! - .-. _ i. i e _ - - .. <br /> V _ <br /> ' Received by t Dat eceipt No, - " <br /> .�- Permit No-�-»> Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />