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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Signltpplication. LJ <br /> F-;R OFFICE USE: APPLICATION JIi� 1 Mi <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN LOC L <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTH DISTRICT <br /> ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joa gin Co u ty Ord' ante No. 1862 and the rules and regulations of the San Jo quin Local ealth District. <br /> Exact Site Address City/Town ' y <br /> Owner's Name Ad. _ Phone.. <br /> ti�° t t ttr.; e.f _ ,r y <br /> Address Cit - <br /> Contractor's Name 1: " -"License# V0 Business Phone <br /> Contractor's Address r Zoo 11d }f ey A r3 } 'Emergency P}ho/n SA `�-- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN E! RECONDITION❑ DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT29 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy j <br /> Sewage Disposal Field. Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> Al INTENDED USE TYPE OF WELL . <br /> 0 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 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 <br /> ❑ GEOPHYSICAL .. w Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �S <br /> PUMP REPLACEMENT: IN state Work Done Re. 6i;� L4b <br /> PUMP REPAIR: ❑ State Work Done p4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> e l <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County O� <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wil I for a Grout Aspecti n prior-to grouting and-a final inspec' <br /> Signed X Title: Date: <br /> i (Draw Plot Plan on Reverse Side) a <br /> i <br /> FOR DEPARTMENT USE ONLY c <br /> PHASE I x Date `-' <br /> Application Accepted By <br /> Additional Comments: <br /> ..Phase II Grout Inspection r Phase III Final Inspection <br /> Inspection By Min Date Inspectio y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITEl PER SITE ❑ EACH ❑ Januar Received'By January 31 r. ❑ July 1 $Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING- . REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L . <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k OTHER <br /> �b2 "7 <br /> Received by ate Receipt No. Permit No Issuance Date Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />