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AppttcationsWill Be,Processed When 5ugmitFed Properly_Corrlptel d. lie Sure To Sign The Application. . `} <br /> FOR OFFICE USE: I <br /> APPLICATION :A <br /> r <br /> 4- (For Non-Transferable, Revocable_;Suspendable) <br /> L PUMP&WALL / <br /> ENVIRONMENTAL HEALTH�PERMIT <br /> (COMPLETE IN TRIPLICATE) f�3-Z../U. A G j�, VyATER QUALITY ': 2 Z8'-l l O-- G� <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct. 4• <br /> This <br /> made in compliance with San Joaquin ou ty Ordin nce No. 1862 and the rules and reguandonsFoftthe San Joaquin he work lLocal cHeeldth Distapplication is <br /> Exact Site Address L ( <br /> CTify/Town _(� 1A <br /> Owner's Name <br /> Address Phone <br /> Contractor's NameCity F <br /> S. License# Business Phone -/ <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate Of Workman's Compensation In urance on f=ile With SJLHD? Yes , x _ No t <br /> TYPE OF WORK (CHECK); NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` <br /> WELL CHLCtRINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank t�r� Sewer Lines <br /> � Pit Privy <br /> Sewage Disposal Field -� Cesspool/Seepage Pit <br /> Property Lino y Other <br /> P Y Private Domestic Well—L�i� Public Domestic Well <br /> INTENDED USE TYPE OF�WELL <br /> r❑,INDUSTRIAL ❑ CABLE TOOL r� <br /> 4d DOMESTIC/PRIVATE Dia, of Well Excavation <br /> ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC Dia. of Well Casing (�'� pj/G <br /> ❑ DRIVEN <br /> Gauge of Casing _ /gip <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IROTARY <br /> 11 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information d <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: + <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: _ ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter I <br /> Approximate Depth <br /> Describe Material and Procedure k <br /> ! 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:"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 /> G <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 rsons subject to workman's compensation laws of California." <br /> I will call for a Cgrout In ect' nor to groutin and a final inspecti <br /> Signed X Title: 7 f t <br /> • Dale: <br /> (Draw P t Plan on Reverse Side) <br /> I <br /> PHASE f FOR DEPARTMENT USE ONLY ) <br /> �Application ( A Accepted By <br /> Additional Comments: Date <br /> -t <br /> Phase It Grout Inspectionr� ` Phase ll! Final Inspection <br /> Inspection By Ln Dated�1�1 _ Inspection By <br /> Date3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31' <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT ' <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE 0 AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> "'s OTHER r s <br /> OTHER <br /> Received b Dae Receipt No. Permit No. <br /> Is uance Date Mailetl Delivered <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITlSERYICES <br /> -J_ _ _ , 1601 E.HAZELTON AVE.,P.O.Box 2009, STOCKTON,CA 95201 <br />