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Applications WIII Be Processed When Submitted ProperlyCompler <br /> APPLICATION <br /> FOR OFFICE use: . I i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> qui n Local Health District for a permit to construct and/or install the work'herein described.This application Is <br /> Application is hereby made to the San Joa <br /> Ordinance No. 1862 and the rules and regulations of the Sannoaquin Local Health District. <br /> made in compliance with San Joaquin County <br /> Exact Site Address Iv City/Town i!9 ? <br /> �" <br /> Phone 769-1 <br /> Owner's Name City ` <br /> AddressBusiness Phone <br /> Contractor's Name <br /> Emergency Phone t <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation I(nnssurance on File With SJLHD? Yes�_f <br /> DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW L A$�ABANDONMENT ❑❑ OTHER ERECONDITION ITI PU❑P INSTALLATION ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WEL <br /> REPLACEMENT❑ 2 Pit Privy <br /> Q4 Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> VIMSewage Disposal Field �' Cesspool/Seepage Pit <br /> .. �Public Domestic Well <br /> Property Line�.�_�Private Domestic Well <br /> INTENDED USE TYPE OF WELL -+ <br /> 13 INDUSTRIAL y oCABLE TOOL Pia. of,Well Excavation �s <br /> Dia. fWell Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLEDa i <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 1 <br /> ATION ❑ GRAVEL PACK <br /> Depth of Grout Seal <br /> X IRRIG <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ` <br /> 1-1 OTHER Other information <br /> ❑ DISPOSAL <br /> Surface Seal Installed By: ��� � <br /> I ❑ GEOPHYSICAL <br /> f PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br />.i PUMP REPAIR: ❑ State Work Done <br /> r <br /> Well Diameter <br /> DESTRUCTION OF WELL: Approximate Depth <br /> Describe Material and Procedure <br /> 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. Y <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 /> 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 /> l permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wil1J all for a Grout Ins ecti prior to grouting and a final inspection. <br /> Title: —� "r�p""w Dake: <br /> Signed X <br /> k .,�.... (Draw Plot Plan on Reverse Side)% <br /> f FOR DEPARTMENT USE ONLY <br /> 4 <br /> I PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: R Phas III Final Inspection <br /> Phase 11 Grout inspection Dat <br /> Date Inspection B �Uly <br /> Inspection lay 0Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ S RecelveRdEMITBy J uly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> I <br /> k LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> / v <br /> Date Receipt No. Is .once ase Mailed Delivered <br /> erm <br /> w F ii No <br /> � Received by 1601 E.H,gZE4TON AVE.,P.O.Box 2008 STOCKTON,CA 85201 <br /> APPLICANT—RETURN,ALL,COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE — _ _ <br />