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cr � Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> /' <br /> (COMPLETE IN TRIPLICATE) (p�6 0 �(f3Crr¢.v [ .tl WATER QUALITY ' <br /> Application is hereby made to the San Joaquin -Local Health Distri� ct fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /Town <br /> Owner's NamePhone <br /> Address yCity V <br /> g � } <br /> =� �• r-=a-- <br /> Contractor's Name License#/� )L 3 73 Busines Phone <br /> Contractor's Address / Emergency Phone - J—. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No j~ <br /> TYPE OF WORK (CHECK): NEW WELL C� DEEPEN 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR a <br /> REPLACEMENT lfd' <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 /> i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing t <br /> ESTIC/PUBLIC-: 11 DRIVEN ` k Gauge of Casing 1 y <br /> _of_Grout.Seal <br /> lGATIF -- ❑-11Depth <br /> ❑ ROTARY Type 3 <br /> 11 CATHODIC PROTECTION a of Grout <br /> ❑ DISPOSAL ? 13 OTHER Other Information - k <br /> ❑ GEOPHYSICAL^ '- `� Surface Seal Installed By: ; W <br /> Q <br /> PUMP INSTALLATION: Contractor O' <br /> Type of Pump <br /> ) � a <br /> PUMP REPLACEMENT: tate Work Donei <br /> PUMP REPAIR: ❑ State Work Done 4 �• <br /> DESTRUCTION OF WELL: Well Diameter #Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby certify that I have prepared this application 'and that the work will be done in accorda6ce with San Joaquin County <br /> ordinances', lawregulations state and rules and rlatiof the San4Joaquin`Local Health District. <br /> nI <br /> Home owner or licensed agent's signiture certifies the following:"I certify that in the performance of the work forwhich 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 j <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." II <br /> I IN all f r a Grout In ection prior to grouting and a final inspection. _ <br /> Signed X � ,� �Title: ,r •Y Date: <br /> (Draw Plot Plan on Reverse ide) 4-. <br /> �r. <br /> (,. <br /> IFOR DEPARTMENT USE ONLY <br /> V. <br /> PHASE i !tt <br /> Application Accepted By { i Date <br /> I Additional Com_rnents:, )` ' <br /> l ,-Phase II Grout Inspection h�1_1l Final inspectionInspection By I Date Inspection ByDate <br /> r , } <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January`1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i <br /> r FEE <br /> LESS <br /> PRORATION .. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt i oO Permit No I IssuanCd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />