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Applications Will Be Processed When SubmittedProperlycompieiea. oeoure rvorvr. r •�•+rr•�a� <br /> t <br /> E use: APPLICATION <br /> x (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and <br /> regulations of the San Joaquin Local Health strict. <br /> Exact Site Address /Y, Vj` r cL'- 4werdzCZ i— A� City/Town (f <br /> Owner's Name N5 a • Phone <br /> -7-3 3 3 <br /> Address D r City <br /> 41, <br /> Contractor's Name 7� Li nse#3i6457'7� Business Phone —af 3 <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 ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLAC€MENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL ,L Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump /Q H.P. <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 will be done in accordance with San7whichthis <br /> unty <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 forrmit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation lawsonia." <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 c ora r ul 4 pection prior to �tingd a final inspectio ^�--Signed XTitle: Date:ot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date z <br /> Additional Comments: <br /> P ase Jkk Grout Inspection a a II Final Inspection <br /> Inspection By- Date Date Inspection By v y ate <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rec,iv d By July 31 <br /> J REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE 1 �CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Ll s Line 4 <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4h3- �74� 3 <br /> Received by Date Receipt No. Permit No. . 0.uance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1s01 E.HAZELTON AVE.,P.O.Bo=20119 STOCKTON,CA 95201 / <br />