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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> FOR OFFICE USE: t APPLICATION <br /> (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WAVER QUALITY <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 Joaquin County Ordinance No. 1862 and the;rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Z 2' J �` -� v _ry City/Town r:. G i'' " 1'" <br /> Owner's Name Phone <br /> Address �(� lfr�¢ .. City ^� ; <br /> Contractor's Name fl���- ,C��� F License#.0%13 63 Business Phone <br /> Contractor's Address t±` e1" —.Emergency Phone = -� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO j sli <br /> TYPE OF-WORK (CHECK):'` NEW WELL❑ 'DEEPEN ❑ RECONDITION❑ - DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMPIREPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank l b O 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) <br /> 13 Excavatio i <br /> DOMESTIC/PRIVATL ❑ DRILLED Dia. of Well.,Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout <br /> t <br /> ❑ CATHODIC PROTECTION, ❑ ROTARY Type of Grout <br /> ElDISPOSAL aTH � ether Information <br /> 11GEOPHYSICALSurface Seal Installed By:' <br /> �.- t <br /> PUMP INSTALLATION: it Contractor <br /> Type of Pump Gov L� H.P. �— I <br /> ( i <br /> PUMP REPLACEMENT: + ❑ State Work Done VPj )t,11e1_ Q <br /> ❑ State Work Done '+, '► <br /> PUMP.REPAIR: n <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material and Procedure - <br /> I hereby certrfythai 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 /> A,. P. <br /> Homeowner or licensed agent's signature certifies the following: ' 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!'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 will c II for a Grout Inspection prior to grouting and a final inspection p i <br /> Signed X. Title: Date: <br /> (Draw Plot Plan on ReverstASide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By `' 'Date <br /> Additional Comments:p <br /> pPhase II.Grout Inspection Atet=Inspection <br /> Inspection By� —M n .Date Inspection By Date v <br /> Fee Is Due:❑ ANNUALLY ❑-PER UNST -- ❑'-PER-SITE ❑ EACH ❑_ January-1 &Received By.January 31 ❑t duly 1 &Received By July 31 <br /> REMIT <br /> — — . 7 <br /> —BILLING.— REMITTANCE—�.�• $ AAADUN}-OIJE""""•"""'CHFCKED- — <br /> -- - BASE -EXPLANATION - DATE DATE *REMITTED <br /> 1 �f .:�'T' - r. a AMOUNT <br /> CT <br /> FEE y, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> r <br /> OTHER <br /> Received by k SIDale J. Receipt No.. Permit To.y „� . 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 />