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„_,_,, ,;;,Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ­70C) � �—�{,t{rq..,J7- ,�OWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instaltheworMed.This application is <br /> made in compliance with San Joa uin County Or an e No. 1862 and the rules and reguIII ati ns o th San Joaquin ocal Hea istrict. <br /> Exact Site Address <br /> i o <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#,,, Business Phone 3 9 33 <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 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL A13ANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Q <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 4 <br /> Property Line Private omestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WEEL 1-2 <br /> ❑ INDUSTRIAL CABLE.TOOL Ua of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9 IRRIGATION E] GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER „ Other Information <br /> ❑ GEOPHYSICAL Surface S I Installed By: \ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4Cr H.P. B2 .J ) <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i.hereby certify that I have prepared-this application and.that the work wall be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations°of the.San Joaquin Local Health District. i <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 /> 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 persons subject to workman's compensation laws of California." <br /> I will call f r a Grout InSpecti prior to grouting and a final inspection. f <br /> Signed X Title: a 1+ ! Date: erO <br /> (Draw Plot Plan on Reverse Side) flFt <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I D <br /> Application Accepted By 1Z Dated?4 J 4 dr <br /> Additional Comments: <br /> Phase 11 Grout Inspection r r Phase III Final Inspection <br /> Inspection By Date J, Inspection By Date AV <br /> Fee IS Due: ❑,ANNUALLY El PER UNIT WPER SITE 1:1 EACH El January 1 &R By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMIT <br /> REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE L---- <br /> LESS <br /> /LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -Date-- No. _P�ermit No-- __ _. Isss- ance Date _ Mailed —Delivered-� -� <br /> APPLICANT—RETURN ALL COPIES To— 'ENVIRONMENTAL HEA1-iH PERMITJSERVICES --j4601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br /> y� r � _ !4 <br />