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l Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign T�e6.pplicaflonbx <br /> ' FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP E61WL, � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> AL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, n�. : <br /> i <br /> F'�'Rfi C"i ✓ <br /> �. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew orkherelr�i'WrJt?e-$-&• l? <br /> jfy nis <br /> made in compliance with San Joaquin Co my rdinance No. 1862 and the ru nd regulations of the San Joa in Local Heai h District. . <br /> - c E Git"Town' <br /> Exact Site Address n v <br /> Owner's'Name <br /> L " Phone= t1 d F <br /> Address Cit <br /> y•. <br /> Contractor's Name ^1 License# 1279616 Business Phoney%l�� ` <br /> Contractor's Address °L •t �` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f No Y <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ _ RECONDITION❑ DESTRUCTION❑ 00 <br /> WELL CHLORINATION ❑ T WELL.ABANDONMENT ❑ OTHER 11W <br /> PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ ii " - t <br /> DISTANCE TO NEAREST: Septic Tank 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 a Dia. of Well Excavation <br /> IX DOMESTIC/PRIVATE .111 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 t Other Information <br /> ❑ GEOPHYSICALi F Surface Seal Installed By: _ - <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done y <br /> f PUMP REPAIR: State Work Done <br /> j DESTRUCTION OF WELL: WeR•Diameter Approximate Depth :( <br /> - Describe Material and Procedure <br /> 1 hereby certify that 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework,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 followings"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 I for a Grout ec• prior to grouting and a final Inspec n. r <br /> Signed X Title: Date: C-� -- <br /> ' (Draw Plot Plan on Reverse Side) <br /> JI- <br /> FOR <br /> FOR DEPARTMENT USE ONLY.., . <br /> PHASE I1- <br /> ' ;; Date <br /> ;. -Application Accepted By - <br /> Additional Comments: <br /> Phase II Grout Inspection I ase 111 Final Inspection <br /> Inspectioni'By 1 �. :Date Inspection By Date lig- 10 A <br /> Fee Is Due: 13 ANNUALLY y ❑'PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> w- <br /> BASE EXPLANATION BILLING REMITTANCE $ - AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED <br /> AMOUNT ' <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER N <br /> f <br /> OTHER _ • - <br /> Received by D to Receipt No: <br /> Permit No. - Is anc ate- Mailed Delivered <br /> APPLICANT— RN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Sax 2009 -STOCKTON,CA 95 <br /> -- 201 <br />