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Applications Will Be Processed When Submitted Property compleieo. oe aure 7u a+yrr rrrcnF+yrrao..v,.. <br /> APPLICATION <br /> FOR OFFICE USE: . <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> i <br /> ENVIRONMENTAL'HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ; <br /> > Application is hereby made to the SanJoaquinLocalHealthDistrictforapermit toconstruct and/or install the work herein described-This application is <br /> made in compliance with San Joaquin County Ord' anca Ny 1662 and the_ ulQs and regulations of the Sar Joaquin Local Health District. <br /> Exact Site Address ?/ =� City/Town <br /> Owner's Name f - i-t k `l�., 6i 'Phone <br /> I Address :vim -' f> t,41z. City X,` ;`` �' Crr <br /> vcji:..�. 1 r;2nse#� Business Phone <br /> Contractor's Name V � �- Z 1- ; " _ k( n <br /> Contractor's Address . ,x - C . Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No v <br /> ' TYPE OF WORK (CHECK): NEW WELL DEEPEN ElRECONDITION❑ DESTRUCTION<] s „`.. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP.REPAIR❑ <br /> I REPLACEMENT❑ ;---r -y ­­ <br /> DISTANCE TO NEAREST: Septic Tank a' # _Sewer Lines 1 Pit Privy ,�-s <br /> Sewage Disposal Field CessPool/Seepaga Pit - Other <br /> Property Line 1- . <br /> t w <br /> Private Domestic Well ' Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL , Dia. of Well Excavation :_ M <br /> ,Q DOMESTIC/PRIVATE "'❑ DRILLED -.Dia, of Well Casing s <br /> 13DOMESTIC/PUBLIC" +❑ DRIVEN Gauge of Casing f'd��� :a VC <br /> . v <br /> 11 IRRIGATION «•� GRAVE//I�PACK -Depth of Grout Seams 1 L_ ' � <br /> ❑ CATHODIC PROTECTION ' .ROTAPiY Type of Grout <br /> k ❑ DISPOSAL ❑.OTHIR Other Information 1 <br /> ❑ GEOPHYSICAL _ Surface Seal Installed $y:, <br /> PUMP INSTALLATION: .'Contra'ctor <br /> ,Type'of Pump N.P' V <br /> 1 PUMP REPLACEMENT: ❑ State Work Done <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 Wort 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 erformance of the work for which this permit <br /> re certifies the following:'"I-certify that in the p <br /> is issued„1.shalt not employ any person in such manner as:to become subject to workman's compensation laws of.California.”. <br /> Contractoes'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 employ persons subject to workman's compensation laws of California. <br /> will Call for a Gr ut Inspection prior- grouting and a final inspectioq ` <br /> Signed X '2.� 'Title'. /� -, .• ".Date:, <br /> .Date s „ <br /> N J <br /> -.(Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted ey "t Da <br /> Additional Comments: <br /> Phase Ii Grout Inspection ha i nspection• <br /> Inspection By Date Inspectlon'By' Dat <br /> i Fee Is Due: ❑ ANNUALLY E3 PER UNIT PER SITE ❑ EACH nJanuary-1'8 eceived By January 31 - -❑ July 1 &"Received By July 31_,. <br /> - REMIT" <br /> BASE EXPLANATION 1 BII LING REMITTANCE $ .-AMOUNT DUE CHECKED <br /> •, ,- DATE +..?.::DATE REMITTED :]-7tMOUNT <br /> FEE <br /> LESS <br /> i PRORATION _ <br /> PLUS - <br /> PENALTY - - <br /> OTHER <br /> r ' - - <br /> OTHER <br /> �9 <br /> Received by Date Receipt No. 4 Permit No. IssuanceDate ;-Mailed Delivered " <br /> APPLICANT—RETURN ALL COPIES TO:_-. ENVIRONMENTAL HEALTH PERMIT/SERvIcEs� � 1601 E.HAZELTON AVE.,RO.6ox 2009 ... sTOCKTON.cA 95201 <br />