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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign mexuNr.a.=� • <br /> APPLICATION <br /> =AT <br /> ; <br /> {For Non-Transferable,Revocable,Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> s�R 4unurY f 3 1 o Sr7-- o/ <br /> E} r3' *2 r0�-�" . 3. a r <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and/or install the work herein described.This application is <br /> made in compliance w'th San Joa uln County Ordinanc N .1862 aF d the Yules a &euo fthe San Joaquin Local Health District. <br /> 4": iVTown <br /> Exact Site Address � _ <br /> � ` Phone ,r <br /> Owners Name f City- `� Q"' � N <br /> AddressLicense 1 i <br /> Business Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address SGI -r� � —� <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ - RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Privy -�-� <br /> �(� { Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank �� Cesspool/Seepage-P'it- Other <br /> /� �� ?sr — <br /> Sewage Disposal 1=i@Id� r -. <br /> Property Line J--�--t- Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> F ❑ IRRIGATION. GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION _ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> [I state Work Done <br /> C1 State Work Done 1 <br /> PUMP REPAIR: � Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter ^ <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 6 <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:"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 <br /> permit is issued, I shall employ persyIs subject to workman's compensation laws of California:" <br /> 1 wi for a Gr ut In ectio�pr' r to grouting and a final inspection. Q <br /> Signed X. <br /> Title: �iV z Date: <br /> {Draw Plot Plan on Reverse i e} <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE i C Date © Z <br /> Application Accepted By <br /> Additional Comments: <br /> ase 11 Grout Inspection Phase III Final Inspection <br /> Date inspection By Date <br /> } Inspection By ® !I� <br /> 7a _- ^ /csry,Y�_f_i_ - <br /> Fee Is Ue' ❑ ANNUALLY ` ❑ PER JNIT u PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received REMIT <br /> uIy 34 <br /> BILLING REMITTANCE, $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION F <br /> PLUS <br /> PENALTY - Ck . <br /> i <br /> OTHER <br /> OTHER <br /> �u <br /> Receipt No. Permit No. -Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,GA 95201 <br /> Received by Date. – <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />