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VApplications.Will Be Processed When Submitted Properly Completed. Be <br /> f4wrets <br /> i, a Application. <br /> FOR_ OFFICE USE: � � APPLICATION tut � <br /> ' (For Non-Transferable, Revocabt (tsoae) <br /> ENVIRONMENTAL PERMIT �9�� PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUA �0 <br /> Application is hereby madetothe San Joaquin Local Health District fora permittoconstruct and/or ir t �k�e-�s,v ��rT(ereindescribed.Thisapplicationis— <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re U4atikF is— <br /> ,. <br /> made tf�e��h oaquien Local Health District" <br /> Exact Site Address ATOwn �! <br /> Owner's Name lef_ _ Phone <br /> i <br /> Address City <br /> Contractor's Name _ License# j� 37.� Business Phone <br /> Contractor's Address to - Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTI ONg <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ L <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..: v <br /> ❑ INDUSTRIAL ❑ CABLE TOOL 'Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing u <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 0 <br /> I <br /> 13DISPOSAL ElOTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor I&I&Iu ," <br /> Ty e of Pump d H p <br /> PUMP REPLACEMENT: State Work Done -'-A- D <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 /> 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. p <br /> Signed X &4nl / ._ �.t r t�J -`-Title: -� am = Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date d r <br /> Additional Comments: <br /> Phase II Grout Inspection Final Inspection <br /> Inspection By Date Inspection 8y Date <br /> k <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> EASE EXPLANATION BILLING REMITTANCE AMOUNT DREMIT <br /> UE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> `7 t <br /> LESS <br /> PRORATION { <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date C Receipt No., - Permit o. �. � Issuance Date .Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES– .r =1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />