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.. UH <br /> a Applications Will Be Processed When u ml e <br /> r Fri{"OFFICE USE: <br /> - -� APPLICATIONS -, <br /> (For Non-Transferable, Revocable, ndal(eJ)L n � q�p�t PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERM�T fd 1 Olt <br /> WATERQUALITY SAN "-;. �I_1 N LOP AL <br /> } (COMPLETE IN TRIPLICATE) jH(g,&fVH.hEDJ <br /> �� IJf described.This application is <br /> I Application is hereby made to the San Joaquin Local Health District far a permit to construct an <br /> -No. 1862 and the rules and regulations of the San I LocaaYHealth District. <br /> made in compliance with San Joaquin County Ordinance <br /> 11 City/Town S <br /> Exact Site Address 6 rI` _ G <br /> Ile <br /> � d� Phone f <br /> Owner's Name 4 City S oe+ S <br /> Address P% �� d' <br /> C+ License#31i L i- Business Phone D' t <br /> Contractor's Name <br /> Q� �� �- Emergency Phone <br /> Contractor's Address WithFile SJLHD9 Yes No <br /> ` Is Certificate of Workman's Compensation in❑suran on <br /> 1:1R CONDITION 11DESTRUCTION❑ <br /> ` TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINA <br /> tTION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR, <br /> f REPLACEMENT,�u� Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines, y <br /> k Sewage Disposal Field <br /> —• Cesspool/seepage Pit' Other <br /> Public Domestic Well <br /> Property I, <br /> Private Domestic Well <br /> INTENDED USE f TYPE OF WELL <br /> ❑ INDUSTRIAL h <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> Dia. of Well Casing <br /> 11DOMESTIC/PRIVATE <br /> I ❑ DRILLED <br /> 19 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal, <br /> ! ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 0 DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> �� - <br /> Contractor ` <br /> PUMP INSTALLATION: H P <br /> T pe of Pump <br /> tState Work Done 4. °+ <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done Q <br /> DESTRUCTION OF WELL: WellDiameter— <br /> u 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 forwhich this permit <br /> t is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> E this <br /> ntractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which <br /> pe�mit is issued, shat mploy persons subject to workman's compensation laws of California." <br /> ` yi <br /> [ 1 I calla r Grout In tion prior o grouting and a sinal inspection. �� � <br /> Date: <br /> Signed X (Draw Plot Plan on Revers Side) <br /> I <br /> I F R DEP RTMENT USE ONLY <br /> PHASE Ia Q y DateU <br /> Application Accepted By <br /> Additional Comments: a'� II F <br /> Pha Iinal Inspection <br /> Phase II Grout Inspection Date <br /> j Inspection By <br /> Inspection Date By - <br /> ❑ ❑ - PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July 1 &ReceivedJuly 31 <br /> Fee IS Due: ANNUALLY PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> k FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1. <br /> OTHER <br /> �y 7-3& �Q <br /> . Receipt No Permit No. Issuance Date Mailed Delivered <br /> Received by Date , <br /> r APPLICANT—RETURN ALL COPIES TO: .-ENVIRONMENTAL HEALTH PERMITISERVICHS. _ 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> ` m <br />