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Applications Will Be Processed When Submitted Properly Completd9e gT A�ica o <br /> FOR OFFICE USE: APPLICATION ##°�� <br /> (For Non-Transferable, Revocable;Suserldable) PUMP JWLL <br /> NOV 9 <br /> ENVIRONMENTAL HEALTH PERMIT 1 $2 <br /> WATER QUALITY Q r; 11" St m <br /> (COMPLETE IN TRIPLICATE) � .�a • t ���, �i P �'/•� <br /> Application is hereby madeto the San Joaquin Local Health District fora 7 .1permit to construct and/or i taile�yywanc��er�}} �Ibed.This application is <br /> made in compliance with San Joaquin.County,Ordinance No. 1862 and the rules and regulations��e�San Yoaquifl'L a1 Health District. <br /> Exact Site Address S �'°• � J City/Town X y <br /> Owner's Name tit ' Phone <br /> City ` <br /> Address ?7, 4 m ' <br /> Contractor's Name rho=-Y�'� License#I/6 :37.3 Business Phone <br /> Contractor's Address Po ! �.�� ���2.e _ Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No <br /> TYPE OF WORK (CHECK): NEW WELL❑ .. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATI N 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT - <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 ;I TYPE OF WELL - � , ,, �-. � <br /> ❑�If4DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i DOMESTIC/PRIVATE ❑ 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 /> E ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: B State Work Done "P <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 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 /> 010 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this ^`1 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ,; W <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X&A �� Title: Date: <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final In ection Z <br /> = Inspection By III r, <br /> Date Inspection By - <br /> Date <br /> Fee Is Due: ❑ ANNUALLY '- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received-Hy January 31 '❑ July 1 &Received By July 31 <br /> REMIT <br /> iBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE a� <br /> LESS r <br /> PRORATION - <br /> PLUS .-.. - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> . Z _S 1 <br /> Received by Date - - Receipt No. Permit No. - Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,1111201 <br />