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LN <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureToSign V <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable;Suspendatiie) PUMP&WELL � <br /> a ENVIRONMENTAL HEALTH PERMIT <br /> _ . WATER.QUALlTY , 071 — <br /> (COMPLETE IN TRIPLICATE)­7 L `f-!�r(pu � } ct r <br /> Application is hereby made to ttie San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made incompliance with San Joaquin County 'Ordinance No.1862gand th Griles and regulations of the San Joaquin Local Health District. <br /> IZAoO City/Town <br /> Exact Site Addres <br /> r Phone' <br /> Owner's Name 4. City "'' p j <br /> Address Business Phone r�Z <br /> License# <br /> Contractor's Name10 Emergency Phone t <br />• Contractor's Address ,f <br /> No <br /> Is Certificate of Workman's Compensation L511 <br /> TYPE <br /> on File th SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION❑ DESTRUCTION �; <br /> WELL-CHLORINATION C1 ...- WELL,A13ANDONMENT ❑ OTHER,� 'PUMPS NST LLATION�i. ..PUMP REPAIR❑. <br /> REPLACEMENT❑ <br /> / Lines nes l Pit Privy , <br /> DISTANCE TO NEAREST: + <br /> .. Septic Tank - I Cesspool/Seepage Pit 1 " T Other <br /> 44a 11 �/� Sewage Disposal Fiel�1 J <br /> /� Public Domestic,Well '1 <br /> Property Line.��,�-�Private Domestic Weil _ — <br />` TYPE OF WELL;'} el <br /> INTENDED USE <br /> Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE�TOOL �f Dia. of i <br /> ❑ DRILLED- '-r) �- Dia. of Well Casing , <br />{ <br /> �DOMESTIC/PRIVATE ❑ DRIVEN ") Gauge of Casing . <br /> DOMESTIC/PUBLIC. <br /> ❑ GRAVE.L PACKS Depth of Grout Seal <br /> IRRIGATION y Type of Grout <br /> Fr <br /> 13CATHODIC PROTECTION ROTARY <br /> !. � <br /> ❑ OTHER Other Information <br /> [I DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> r H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done\N' N <br /> PUMP REPAIR: ❑State Work Done <br /> YIAL� Approximate Depth ' <br /> DESTRUCTION OF WELL: WellDiameter <br /> j —Describe Material.alid Procedure _ <br /> prepared this a lication and that the work will be done in accordance with San Joaquin"County <br /> I hereby certify that I have prep pp <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's-sig nature certifies Shnc <br /> eYollowing: I certify that inth epoekmanas cvm nsationrk f laws of California.or which this t ] <br /> is issued, I shall not employ any person in.such manner as to become subject to <br /> Contractors hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this ( �e <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit I a rout spe for to grouting and a final inspection. , <br /> Signed X + i TitleI <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �r <br /> FOR DEPARTMENT U �•9SE ONLY ' <br /> PHASE 1 {�� Date <br /> 1 Application Accepted By € <br /> Additional Comments: base III Final spection �� <br /> Phase Il Grout Inspection Date <br /> 1 Inspection By - <br /> Inspection By y Date <br /> i <br /> R SITE ❑ EACH E3 January 1 &Recei y January 31 ❑ July 1 &Received EByITuIy 31 <br /> Fee Is Due: Cl 'ANNUALLY ❑•PER.UNIT ❑ PE <br /> BILLING REMITTANCE $ AMOUNT DOE CHECKED <br /> BASE, EXPLANATION DATE DATE REMITTED AMOUNT <br /> it Lic <br /> FEE <br /> k _ <br /> LESS �F r <br /> PRORATION <br /> PLUS - <br /> PENALTY. <br /> 'x _ <br /> OTHER - <br /> OTHER <br /> _ v <br /> F -- - Mailed Delivered <br /> Permit No. Issuance Date <br /> Received by Date Rece t o. <br /> - APPLICANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.Hp,ZELTON AVE.,P.O.90:20D9 STOCKTON,CA 95 <br />