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Applications Will Be Processed When Submitted Properly Compfeted. Be Sure To Sign The Application. «� � <br /> APPLICATION j <br /> R OF ICE USE:-" , <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ !ATEfi QUALITY { �—0 4 O—0? <br /> (COMPLETE IN TRIPLICATE) <br /> yC- GJ:- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor'instalI the work herein described.This application is <br /> made in compliance with S n J9 uin Cou din 8 ce No. 1862 and the r les and a lations of the San Joaquin Local Health District. 4 <br /> Exact Site Address I City/Town <br /> Owner's Name <br /> �-, �f Phone <br /> Address . ,.;., City <br /> Contractor's Name a License-# �" � — Business Phone. <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 WELLI' 'DEEPEN ❑ RECONDITION Q DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-0 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank k 00 Sewer.Lines Pit Privy <br /> r Sewage Disposal Field 1 OQ�''�_ Cesspool/Seepage Pit Other ' <br /> Property Line lC7 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> tff DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing» # 0c s_c\ l <br /> ❑ IRRIGATION �. ..�- - ® GRAVEL PACK ��.. Depth of Grdtit`$eal SCZ`\\ <br /> i ❑ CATHODIC PROTECTION w ® ROTARY 4 Type of,Gr4out <br /> "1 <br /> ❑ DISPOSAL r ` ❑ OTHER Other Ihformation <br />! ❑ GEOPHYSICAL f { Surface,S,eal Installed By: <br /> PUMP INSTALLATION: r Contractor <br /> ...�. Type of Pump.-- <br /> , I,t ; <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_ t <br /> r 4 <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.andF 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 /> is issued, I shall not employ any person in-such rrlann2l a"s to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contrlicting 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." 6 <br /> I will call for a Grout Inspection prior to grouting and a fins inspection. <br /> �� ���, r Date: <br /> Signed Tule: S <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout inspection Phase III Final Inspection <br /> on By Date. FF <br /> Inspection By Date Inspecti <br /> it <br /> Fee Is Due: C3ANNUALLY PER UNIT ❑ PER SITE ❑ EACH_ - ❑ January 1 &Received By January 31 .6 July 1 &Received <br /> R MlTuly 31 <br /> EXPLANATION BILLING REMITTANCE_ $ AMOUNT DUE CHECKED <br /> BASE <br /> rr DATE DATE REMITTED t AMOUNT <br /> F FEf - <br /> L <br /> LESS <br /> PRORATION 4 4 <br /> PLUS <br /> PENALTY L <br /> OTHER <br /> OTHER <br /> rr - <br /> Received 4y a e Receipt No. . Permi4 No 'Issuance Dale ' Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1607 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />