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i �wr #o g lacy p <br /> Applications Will Be Processed When Submitted Property Co t d e i T A I tion. <br /> FOR,9FI'�E USE: t <br /> APPLICATIQN � <br /> (For Non-Transferable, Revocable, Spend4PfZ 25 1980 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �' WATER QUALITY SAN J+FAQ#UIN LOCAL. <br /> �jl hegl§ThRICT <br /> Application islierebymade tothe San JoaquinLocal Health.Districtforapermittoconstructanel I ork, erein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_�_/_� � c� r <br /> �� City/Town <br /> Owner's Name FiP Phone <br /> Address � <br /> City <br /> Contractor's Name <br /> License#.. (>yQBusiness Phone <br /> Contractor's Address _ !� _ Emergency Phone, yl�� '/r/ -1� <br /> r <br /> Is Certificate of Workman's Compensa Ion Insurance on File With SJLHD? Yes r� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ ` <br /> 7 <br /> DISTANCE TO NEAREST: Septic Tank `�� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ,w <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor AO <br /> pe of Pump <br /> TyH.P. <br /> PUMP REPLACEMENT: ❑State Work Done r <br /> PUMP REPAIR: S,tate 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. 09 <br /> Home owner or licensed agents 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 for which this <br /> permit is issued, I shall emIoy persons subject to workman's compensation laws of California." <br /> dl C I for a Gro t I ctton or to gr ng and a final inspection. I <br /> Signed X C- _ Title: v <br /> Date: <br /> # (Draw Plot Plan on Reverse Side) <br /> FO DE RTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT N -PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 � <br /> BILLING REMITTANCE REMIT <br /> BASE- EXPLANATION $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r� <br /> LESS J <br /> PRORATION <br /> PLUS <br /> r <br /> PENALTY , •I.. _ ,. _-� .; ,ti .__ "yam - <br /> %y <br /> OTHER <br /> x,.-OTHER -_ a <br /> Received by ''Y; Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIGES <br /> N-- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 � <br />