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Applications Will Be Processed When Submitted Properly Completed.Be SureToSignTheAppHcauon. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL i <br /> ENVIRONMENTAL HEALTKPERMIT <br /> I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Local Health District for a permit canstructand/or install the work-herein described.This application Is <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin County O 'nance No. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address C1 City/Town I <br /> I, 1 <br /> r <br /> Phone.. <br /> Owner's Name City ' <br /> Address --S �"""�a_i.'. <br /> Contractor's Name _E?�e—�-- y <br /> _..� License Business Phone <br /> Contractor's Address ` t Emergency Phone•?. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L� No ' <br /> TYPE OF WORIN O WELL ABNb�WELLANDONMENT 1:1 OTHER ❑DEEPEN EY -RECONDITION-0PMP INSTALLATIONS PUMP REPAIR❑ <br /> WELL CHLOR ! <br /> REPLACEMENT❑ <br /> Sewer Line <br /> DISTANCE TO NEAREST: Septic Tank E s 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 /> ❑ 1! STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 93'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 9 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP,,INSTALI_ATION: Contractor `� H P <br /> Type of Pump <br /> PUMP REPLACEMENT: 11 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify <br /> if that l'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 /> i Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l t a Grout Insp tionlprior to grouting and a final inspection. . <br /> Signed X <br /> _ Title: _ Perse <br /> Date: 7 _�(Draw Plot Plan on ReSide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I v Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout inspection Phas Fin nspeclion 1 Y <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PERU NIT ❑ PER SITE [3 EACH ❑ January 1 &Received By'January 31 E] July 1 &ReceivedREMIT 31 <br /> • BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS { <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Delivered <br /> Received by Date _ _ - - _ <br /> Receipt No Permit No. Issuance D e„. Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />