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Applications Will Be Processed When Submitted PropeCopleted, Be Sure To Sign The Application. _ ~ <br /> [FOR OFFICE USE: rlym <br /> APPLICATION <br /> (For Non-Transferable,'Revocable:Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) e V', � �L{��yy� TE nLlrr [�_ 7/ <br /> ' Application is hereby mad to the San Joaquin Loca Heap#ip rictfoiapermittoconstructand/or install the work her ndescri2-2 ThisUappficationis <br /> made in compliance San Joaquin County Ordin No. 1882 and the MM and regulations of the San uin Local Health District. <br /> Exact Site Addr ss L —� <br /> C �A <br /> City/Yawn 1/t <br /> Owner's.Na e <br /> Addres c Phone Q . <br /> Contractor's Nam City <br /> V C License# <br /> Business Phone`''► , -41 <br /> Contractor's Address Gu Emergency Phone E <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ , <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ M 1\; <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestia-W Other <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE � Dia, of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing I <br /> ❑ DOMESTIC/PUBLIC <br /> El DRIVEN <br /> ❑ IRRIGATION ± Gauge of Casing <br /> € ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ - ! , <br /> ROTARY Type of Grout - v� <br /> ❑ DISPOSAL ❑ OTHER C �. <br /> ❑ GEOPHYSICAL r Other Information k <br /> y Surf Seal Installed By: <br /> PUMP INSTALLATION: t <br /> Contractor i <br /> Type of Pump �1 H.P. d? I F <br /> PUMP REPLACEMENT: + . ❑ State Work Done <br /> PUMP REPAIR: # ❑ State Work Done a <br /> DESTRUCTION OF WELL:' <br /> Well Diameter �_ Approximate Depth , <br /> f 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in theperformance of the work for which this permit L <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> per issued, I shall employ persons sub' ct to rkman's compensation laws of California." , <br /> I 'wl C201 for a Grout Sp ction prior 1 r ting d a final insp ' n <br /> Signed X Title: r� <br /> Date: <br /> (Draw Plot Plan on Reverse Side) ,- <br /> Q FOR DEPARTMENT USE ONLY ` <br /> PHASE I <br /> o f <br /> Application Accepted By pi <br /> Additional Comments: I Date <br /> Phase Il Grout Inspection h e III Final Inspection <br /> Inspection By } bate Inspection By Dat41R. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH �❑ Januar 1 &Received jf <br /> Y y Jan ry 31 JulyyJuly 310 <br /> l BILLING REMITTANCE 'REMIT <br /> EXPLANATION $ <br /> ! DATE PATE REMITTED AMOUNT DUE CHECKED <br /> y„ <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATI <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER <br /> OTHER - - - <br /> Received by Date Receipt No Permit No,- ' d' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ssuanC ate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2OIt9 STOCKTON,CA 95201 ' <br />