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Applications Will Be Process ad When Submitted Property Completed; Be Sure To Sign The Application. u <br /> FOR OFFICE USE: I APPLICATION, `C� 7 <br /> ,ton-Transferable,Revocable,Suspendable) PUMP& WELL• ((/L�� <br /> ENVIRONMENTAL HEALTH PERMIT ,L D T__ <br /> �( 3 <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 Sart Joa uin Count�,iOr Inance No. 1662 and the rules and regulations of the Sen Joaquin Local Health District. <br /> Exact Site Address V�/ltP�-�- �'Citylrown — <br /> S <br /> Owners Name Voll ` Phone[1.3�e ' 0 '�'-z— <br /> Address Hq e,� - 6, !T7`-' City _ _ <br /> Contractor's Name l p/ w License#3?,F6Q ( Business Phone '� 1 t <br /> Contractor's Address tea- rt == Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes T_ No d <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,N,❑�- <br /> WELL CHLORINATION ❑ WELL,ABANDONMENT C3 OTHER 13 . PUMP INSTALLATION r!— PUMP REPAIR <br /> REPLACEMENTQ <br /> DISTANCE TO NEAREST: Septic Tank I 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 /> ❑� INp USTRIAL Q CABLE TOOL Dia.of Well Excavation <br /> cT/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 1 - Surface <br /> Seal Installed By: <br /> PUMP INSTALLATION: - Contractot.. ' <br /> Type of Pum[,i. -�-¢�� H.P. <br /> PUMP REPLACEMENT: ❑ State Work:Done <br /> PUMP REPAIR: ❑ State Work Oone <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure 0 <br /> rn <br /> T^ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County _Q <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 follow Ing:"Icertify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ any person in Such manner hs to become subject to workman's compensation laws of California." <br /> Contractorsub- <br /> contracting hiring or subontracting signalute 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 wit all fair Grout Ins tion prior to grouting and a final inspection. <br /> Signed �--- Title: t"u�✓�� Datl: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASEI <br /> Application Accepted By. �.!' - ,' - Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph e I anal Inspection / 2� `v/ <br /> Inspection By— <br /> y Date Inspection B Date ro <br /> Fee IS Due: 13 ANNUALLY Q PER UNIT [I PER SITE '❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> AMOUNT <br /> FEE <br /> DATE DATE REMITTED <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuance Dale Mmled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE..P.O.Be.2009 STOCKTON.CA 95MI <br />