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Applications Will Be Processed When Submitted Properly Completed. Be SureToSign ineapptica>:iars. <br /> APPLICATION <br /> FOR OFFICE USE: .• <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT Yom . <br /> (COMPLETE IN TRIPLICATE) 14'7 ? Z. -S'- i v+��L+4ri� WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wixli San Joaquin County Ordinance No.1862 and the. rules and regulations of the San J aquin Local Health District. <br /> G City/Town �� °1 <br /> Exact Site---.--- <br /> Phone '' <br /> Owner's Name citys r fi <br /> Ad d ress <br /> Contractor's Name .aF �,� `J// License# Business Phone - <br /> Contractor's Address ,moo t3.tr _!Z_ La�®- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No - <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 13PUMP INSTALLATIONi PUMP REPAIR 13 <br /> REPLACEMENT❑ i <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 ,,,j, ,..��- TYPE OF WELL it <br /> ❑ INDUSTRIAL J ;gil,'°1��,�� ❑ CABLE TOOL Dia. of Welk Excavation_ <br /> r/ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION GRAVEL PACK Depth of Grout Seal / <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout » <br /> ❑ DISPOSAL ElOTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal installed By: 11101mvee4e eie _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: r❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done j <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth v <br /> i Describe Material and Procedure <br /> �l <br /> s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f, <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 € <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XX r Title: Date: "sp �- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 x Date <br /> Application Accepted By <br /> Additional Comments: ; <br /> h 11 Grout Inspection Phase Ili Final Inspection <br /> �� b 1s _3 <br /> Inspection By Date—�� �iy Inspection By Date <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received REMITuly 31 <br /> BASE i EXPLANATION 'BILLING REMITTANCE $ AMOUNTOUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE iLBI <br /> LESS <br /> PRORATION - - - <br /> PLUS <br /> PENALTY _ <br /> f. <br /> OTHER <br /> a <br /> OTHER <br /> Received by I Da10 Receipt No. Permit No. Issua ce 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 /> f - <br />