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- — <br /> Applications Will Be Processed When Submitted roper y , <br /> x APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> " WATER QUALITY -� <br /> (COMPLETE,IN TRIPLICATE) <br /> aquin Local Health Districtfora permit to construct and/or install the work.herein described.This application Is <br /> Application is hereby made tothe San Jo <br /> made incompliance with San Joaquin County Ordinance No. 1862 and a rules and regulations of the San Jo n Local Health District. <br /> City/Town <br /> Exact Site Address <br /> q� n � Phone `7"' <br /> Owner's Name c�t� City v� <br /> Address <br /> � ' � ov, <' � �• License# �.Sr Business Phone <br /> Contractors Name <br /> a Emergency Phone <br /> 1 Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File�WiJLHD? Yes_ _— <br /> ,� RUCTIONO <br /> TYPE OF WORK (CHECK❑)'- WE WELL <br /> AB,�DONMENT ❑DEEPEN ❑ OTHER-0�RECONDITION <br /> ❑ ITI PU❑P INSTALLATION <br /> DEST ❑ PUMP REPAIF{� <br /> WELL CHLORINATION <br /> REPLACEMENT 111 Sewer Privy <br /> sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Cesspool/Seepage Pit Other <br /> Disposal Field <br /> Property Line _ Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE <br /> t TYPE OF WELL 13 INDUSTRIAL <br /> of Well Excavation <br /> INDUSTRIAL ❑ CABLE TOOL y <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ll IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Nps <br /> 11 ROTARY Type of Grout <br /> El CATHODIC PROTECTION Other information S <br /> 13 DISPOSAL <br /> E] OTHER <br /> M 13GEOPHYSICAL I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,�„� r•` H.P. l ( <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> State Work Done u <br /> PUMP REPAIR: Approximate Depth <br /> t DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County d <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance Of the work for which this perm.". , <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Californiathe following:,I certify that in the performance of the work for which <br /> Contractor's hiring or sub-cthis <br /> ontracting signature certifies <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 11 for a Gr- t I pecllon prior to grouting and a final ins ectlon. <br /> Title: " `Date: <br /> F Signed <br /> (Draw Plot Plan on Reverse ide) <br /> FOR EPARTMENT USE ONLY <br /> PHASE 1 _ '' Date <br /> Application Accepted By <br /> Additional Comments Phase til Final Inspection <br /> Phase If Grout Inspection Date <br /> pate Inspection By <br /> + <br /> Inspection <br /> 1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ - REMIT <br /> BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> ___�FEEv c+y <br /> ' LESS eW <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER _ <br /> OTHER <br /> 63 <br /> Received by Date Receipt No. <br /> Permit Na lssuance Date .� Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.aaK 2009 STOCKTDN,CA 95201 <br /> _ APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> __ <br />