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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> _r <br /> FOA'UFICE USE: , { APPLICATION ( Z •--6�=07 <br /> �""f (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �� <br /> = fL CJ vt�"T <br /> (COMPLETE N TRIPLICATE) / " r f �� / � WATER QUALITY <br /> �/�0 �. <br /> Application ma de to the San Joaquin Local Health District fora permit to construct and/or install the work herein de scribed.Thlsappllcatl�s <br /> _ Pp Y /?/ � <br /> made in compliqnCe;00' Zoaquinunty,.Ordinance No. 186 and t e r les and regulations of the San Joaquin Lo ai Health Chis ct.Exact Site Addr7 �Fd �° City/TownOwner's Na at � Phone 62Address City Contractor'sNa `F a• icense# BusinessPhone <br /> Contractor's Address � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Q <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 11 PUMP (PUMP INSTALLATION ❑ PUMP REPAIR4 ) <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit �Q Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �,C(� <br /> 11 INDUSTRIAL 1 11 CABLE TOOL Dia. of Well Excavation .. `7 <br /> `❑ DOMESTIC/PRIVATE - 'N ,4"`€ ❑ DRlL'LED11 Dia. of Well Casing el <br /> tk DOMESTIC/PUBLIC �❑DRIVEN Gauge of Casing <br /> ❑ IRRIGATION -7- ��fu ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION L ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 1' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t a <br /> PUMP INSTALLATION: Contractor <br /> t <br /> [ Type of Pump t H.P. <br /> i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: +" ❑ 'State Work Done <br /> DESTRUCTION OF WELL: WeII Diameter. ) Approximate Depth <br /> Describe Material and Procedure <br /> I 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:',1 certify that in the performance o1 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 o1 California." <br /> { <br /> —following:"l certify that in the performance of the work forwhich this <br /> Contractor's hiring orsub-contracting signature certifies the <br /> permit is issued, I shall employ persons subject to workirian's compensation laws of California." <br /> II cat for"a-Gr_o�t Ins tion prior gro Ing and a final'inspection.; <br /> ,(1110 <br /> Signed X Title: _ - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> h E FOR DEPARTMT.USE ONLY <br /> PHASE I <br /> Application Accepted By Date - <br /> 1 <br /> Additional Comments: <br /> {€ Phase II Grout Inspection Ph 11 Final I pection f <br /> F Ins ection B Date 49! <br /> Inspec ion B�i - Date � P Y <br /> I 41A O _, _ <br /> Fee Is Due: ❑ ANNUALLY' PER UNIT�•❑ PEIt'51TE .❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> i- REMIT <br /> I. BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I 4 <br /> 'BASE f EXPLANATION � GAT.E.,.,.� DATE REMITTED <br /> AMOUNT <br /> FEES r.. 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �,3o Tdg L � u <br /> Received by Date Receipt No. —Permit No. Issuance Date Mailed Delivered <br /> ICES tfiol E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERV <br />