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Applications Will Be Pro es <br /> When Submittedro er y a is 1 <br /> FOR OFFICE USE: /„ lo, � APPLICATION <br /> W - <br /> {For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> and/or install the work <br /> WATER QUALITY ,,,_ <br /> (COMPLETE IN TRIPLICATE) <br /> Ap�lica4on`is hereby made to the San Joaquin Local Health District fora permit to construct herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc No.1862 and the rules and regulations of the San Joan" al Health District. <br /> , ^� City/Town <br /> Exact Site Address <br /> a Phone <br /> ,Owner's Namet�t �,P�t City -.�`�t�e fin <br /> Address � � <br /> Business Phon <br /> se �� <br /> Contractor's Nam License# �� <br /> Emergency Phone <br /> Contractor's Address No <br /> I Is Certificate of Workman's Compensation Insurance on Fi With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN 13RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION© PUMP REPAIR <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEARESTT Septic Tank Sewer Lines y <br /> Sewage Disposal Field - <br /> Cesspool/Seepage Pit Other <br /> Property.Line Private Domestic Well Public Domestic Well 1 <br /> INTENDED USE <br /> TYPE OF WELL <br /> 11 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation y <br /> 11 INDU STIC/PRiVATE ❑ DRILLED Dia. of Well Casing <br /> - ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> 11 GRAVELPACK Depth of Grout Seal <br /> 11 IRRIGATION _ <br /> 11 CATHODIC PROTECTION 11 ROTARY Type of Grout + <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pumper h' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> yDESTRUCTION OF WELL: Well Diameter . <br /> i <br /> Describe Material and Procedure <br /> y ,r <br /> F <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. Ft..� � <br /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for laws <br /> o which alifor ia." <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> k 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 employ persons subject toYworkman's compensation laws of California." T <br /> I will call for a Grout Inspection prior o utini a final inspection. <br /> A, 0 e. r0,0 Date.. <br /> Signed X <br /> {Draw Plot P on Reverse Side) ` <br /> i, FOR DE ARTMENT USE ONLY ' ir <br /> PHASE I is Date <br /> Application Accepted By <br /> Additional Comments: . ha 111 al inspection <br /> Phase II Grout Inspection <br /> Inspection By .'Date Inspection By ��� Date <br /> 1. i <br /> Fee IS Due s ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> 3 EXPLANATION BILLING REMITTANCE `� AMOLfNT DUE CHECKED <br /> BASF DATE DATE REMITTED - AMOUNT <br /> yf <br /> ys t/ <br /> FEE `L <br /> LESS <br /> PRORATION'. <br /> 3 PLUS <br /> PENALTY <br /> i <br /> r <br /> OTHER <br /> r _ <br /> OTHERt} M1 .• <br /> ■ C/cq.l� ��� �1 issuance Date Mailed Delivered <br /> W - Permit No- <br /> - Received by - Date V�'— -�,/ RIA �� 1601 E.HAZELTON AVE.,P"O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIR N ENF <br /> -HEALTH PERMITISERYICES ,�M <br />