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T <br /> Applications Will Be Processed When Submitted Properly Completed,Be Sure ToSignThe <br /> rFOROFF�lCE USE: APPLICATION(For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ... .;_. ATER UA ITY <br /> (COMPLIETE IN TRIPLICATE) 'ZZ?SL�..._ '� '�S4c-pgwt f <br /> Application is hereby made to the San Joaquin Local Health District fora perms tocand/or install the herein described.This appli <br /> onstruct cation is <br /> oaq in County Ordinance No. 8 2a the rul s an re I Vons of the San 4paquin��Health District. <br /> made in compliance with San J <br /> /Town . �!L <br /> Exact Site Address E <br /> Phone <br /> Owner's Name d <br /> City � <br /> Address Business Phone X1__ <br /> Contractor's Name ►Z �¢[ icense t <br /> -Emergency Phone <br /> Contractor's Addres No <br /> Is Certificate of Workman's Compensation IInELL�ns�surance on File With SJLHD? Yes _ - <br /> DESTRUCTIONO <br /> TYPE OF WORK (CHEC <br /> NEW L,ASAIVDONMENTE❑DEEPN © OTH p0❑ 1T10 RECNDU❑P INS LL <br /> ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION W <br /> REPLACEMENT❑ ( Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal FiF1d ' <br /> cesspool/Seepage Pit - Other <br /> Property Line Private Domestic Well,!� � <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing r <br /> ❑ DOMESTic/PUBLIC 13DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> 13 ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION - •�-"- O� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' H.P. <br /> 7 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> I 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 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 ubject to workman's compensation laws of California." <br /> } <br /> 1•1 will call for a Gr ut In ction or o grouting and a final inspection. ` <br /> Title: �^ " Date: <br /> Signed X. <br /> (Draw Plat Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I GL l Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase I11 Final Inspection 01 <br /> Phase II Grout Inspection <br /> Inspection ByDat- erg` <br /> Inspection By Date �1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &ReceiveRd By July'31 <br /> BILLING _ REMITTANCE $ AMOUNT DUE CHECKED <br /> i - BASE EXPLANATION DATE DATE - REMITTED AMOUNT <br /> FEE 1� r <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER - - <br /> OTHER <br /> Receipt No. Permit No. -- –I suance ate- Mailed Delivered <br /> Date Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />