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Applications Will Be Processed When Submitted Properly Completed Besure Io algn I„M -----r° <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY , .. <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin LOrdlinanceNo. 1862andHealth District for�a pthe rulosandrectuiationsofttheSanJoaquin)LocalHealth.Districtapplication+s <br /> made in compliance with San Joaquin Count O te City/Town <br /> Exact Site Address �� r <br /> ' Phone <br /> Owner's Name f City <br /> Address *License Business Phone, '°+- - i <br /> Contractor's Name �, / ,,.. Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> E WELL <br /> ❑ RECONDITION <br /> ❑❑ <br /> REPAIR 13 <br /> TYPEOF WORK (CHECK <br /> -NEW <br /> ❑ OTHER ❑ UDP INSTALLATION aPUM <br /> WELL CHLORINATION ) <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit \ 0 Other <br /> Sewage Disposal Field <br /> Property Line <br /> Private Domestic Well Public Domestic Well\ <br /> 1 DED USE 6 TYPE OF.WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> 11DOMEST.ICIPRIIIATE Gauge of Casing <br /> �, t £ ❑ DRIVEN <br /> ❑ DOMESTICYPUBLIG,�y Depth of Grout Seal <br /> ❑ IRRIGATION E] GRAVEL PACK p <br /> 13 ROTARY Type of Grout AL <br /> El ; y, <br /> ElCATHODIC PROTECTION ❑ OTHER Other Information' ' <br /> ❑ DISPOSAL <br /> �""^•� �Y,Su•l�face Seal Installed By:� <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor - ` . H.P. <br /> 't' I <br /> . Type of Pump <br /> PUMP REPLACEMENT: �.- ❑ State Work Done € ! <br /> PUMP REPAIR: ❑ State Work Done V <br /> Approximate Depths <br /> !; <br /> pESTRU740N OF WELL: Well.Diameter „: <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 Joaquinu 1� p <br /> I f the work orwhich this f <br /> ordinances, state laws, and rules and"�regul�tions of the San Joaquin'Local Health District. <br /> Home owner or licensed agent's signatuelc rtif s 1k ch ntannerhe las to becomowing:"I e subject to workmany that in the 's compensationnce 0 laws of California. <br /> is issued, I shall not employ any person <br /> I Contractor's hiring or sub contracting signaturecertiiles 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 /> t / <br /> I will caar a Grout Ins ection prior to grouting and a final inspection.J�JDale: 3 <br /> 4 Title: <br /> Signed X (Draw Plot"•Plan on Reverse Side) <br /> ; <br /> t 4 <br /> FOR DEPARTMENT USE ONLY01 <br /> JY/ <br /> r 4 <br /> PHASE I Date "... <br /> Application Accepted By <br /> Additional Comments: 3 <br /> Phase I Inspection <br /> Phase II Gr. Inspection ate <br /> Inspection By <br /> Date Inspection By <br /> ANNUALLY ❑ PER UNIT PER SITE ❑ ICH '❑ January 1 &Received By January 31 ❑ Ju4y 1 8.Receiv REMITd By 31 <br /> Fee IS Due. ❑ AN 4 $ CHECKED * \ <br /> _BILLING i�REMITTANCE. AMOUNT DUE AMOUNT <br /> BASE 1 EXPLANATION DATE DATE REMITTED <br /> FEEy"`•�-:""' � ....o....-,-.._.. '..,.^-,�...,.� .. `;;�� / <br /> LESS <br /> PRORATIONPLUS <br /> sY •..� , `' rA b w int;�i' �.,�"" -- '" _ <br /> PENALTY C- <br /> �� <br /> OTHER <br /> ' r <br /> OTHER <br /> A_N / issuance Date Mailed Delivered t <br /> Receipt No. _ Permit No.. _ - <br /> Rec v d by .- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> Rate <br /> A LICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM17lSERYICES <br />