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YQp1i�atiens Will Be Processed When Submitted Properly Completed.Be Surf tTSign TheApplYcaTon. R! pf , <br /> _-,r APPLICATION �� iJ� <br /> r; f bFFICE US tf' 'i JUL� PUMP��� <br /> . - a (For Non,Transt rab e,$tevoc�a lfe; Suspendable) <br /> f ENVIRONMENTAL HEALTH PERMIT - `'�''�''"'� <br /> ��: 7 SAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY L)1S ;?!C t <br /> App[icativn is hereby made to the San Joaquin Local HealthDi construct and/or install the work herein ed.This application is <br /> de <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules d r! u1 tions of the Sa Jo quip Local Heaith District. <br /> Exact Site Address City/Town <br /> � � 7 <br /> Y+ qty Phon- ? <br /> Owner's Name uj �J <br /> Address � City _ <br /> Contractor's Nam I� 4-5 /U License#/, Business Phone <br /> Contractor's Address. <br /> rr�, �4L 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 E3WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E�'� PUMP REPAIR❑ r { <br /> REPLACEMENT❑ p Sewer Lines�d Q Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank 46 <br /> Sewage Disposal Field Cessp000�l,/,S,,e�epage Pit, Other. <br /> Property Lin/±Z p�/ <br /> Private Domestic Well � Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL fl?CABLE TOOL Dia. of Well Excavation `. .r <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 'ad <br /> 00 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ' I <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ;f <br /> Type of Pump •• ,"'tel H.P. r <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 San Joaquin County <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." _ f 4 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this 1.. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. F.., <br /> ��Z� �, .. <br /> Signed X _�--% Title: <br /> Date: '1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> Dat <br /> Application Accepted By <br /> Additional Comments: <br /> Pha 11 Grout Inspectl n ha a final Inspecti <br /> Daer� <br /> e Inspection Byu / <br /> Inspection By SZ � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBAITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT r F <br /> i <br /> FEE <br /> LESS <br /> PRORATION _ . <br /> PLUS <br /> PENALTY ` <br /> OTHER <br /> OTHER 4 <br /> Mailed nce e <br /> Perm s No. ua DatDelivered <br /> c ReceToedhy•__ gDate - - Receipt ' <br /> APPLICANT-RETURN A JRQNMENTy HEALTH PERMIT/SE ICES 1601 EELTON AVE.,P.O.�az 2009 STOCKTON.CA9520 <br />