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.. ... <br /> - Applications Will Be Processed When Submitted Properly .yy <br /> FOR OFFICE USE: APPLICATION 1 <br /> (For Non-Transferable, Revocable, Suspendable) i PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _.. TER QUALITY — <br /> (COMPLETE IN TRIPLICATE) " S^17 S_ ��✓1�- <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�`w-• 7 <br /> made in compliance with San Joaquin County OrdinancereCit <br /> - No. 1862 and the rules and _g�ul�atio of the San Joaquin Local Health District. <br /> City/Town t <br /> Exact Site Address <br /> �A� Phone �� 7 CT 3, <br /> Owner's Name City <br /> C. ..�. <br /> Address / �(p Business Phone. <br /> Contractor's Name CfP�. � License# —� <br /> Contractor's Address it Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? Yes---! <br /> No <br /> t TYPE OFCHLORINATION WORK ( I0 WE WELL. NDONMENT ❑DEEPEN ❑ RECONDOTHER [I 1T10p❑P INSTALLATION O❑❑ PUMP REPAIR❑ <br /> y WELL <br /> REPLACEMENT Pit Privy - <br /> DISTANCE TO NEAREST: Septic Tank �s � Sewer Lines y Other <br /> Cesspool/seepage Pit <br /> Sewage Disposal Field_ �!�+F AP i <br /> Property Line��� Private Domestic Well <br /> Public Domestic Welli <br /> INTENDED USE TYPE OF WELL d <br /> 11 INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing j ^� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasingZK <br /> tin <br /> IGATION ❑ GRAVEL PACK Depth of Grout Seal RRr <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> ell <br /> PUMP INSTALLATION: Contractor iS� �'� <br /> H.P. <br /> Type of Pump t <br /> 8-State Work Done <br /> PUMP REPLACEMENT: <br /> I ❑ <br /> PUMP REPAIR: State Work Dane <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I <br /> I I hereby certify that'l 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:"I certify that in the performance of the work for which this permit <br /> f 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:"1 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 Inspectio prior to grouting and a final inspection. <br /> I 11 Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLYAii <br /> ' <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> t <br /> t Phase III Grout Inspection ha I Inspection <br /> Inspection By Date <br /> 1� Date '. <br /> Inspection By.�—t 1 <br /> Fee Is Due'_ ❑ ANNUALLY ❑ PER UNIT - ❑ PER SITE ❑ EACH El January I &Received By January 3t ❑ July 1 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> l <br /> ! PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> DReceipt No. Permit Na. mi 1: a <br /> ate Date ailed Delivered <br /> qtr, Received by - 1601 E:HAZELTON AVE..P.D.Bos 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />