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_ ,r.�----•-�-..,.�_ - _ n ......err <br /> Applications Will Be Processed When Submitted Properly o <br /> Fob OFFICEusE: ���y APPLICATION <br /> a4, /I. or(FNon-Transferable, Revocable, Suspendable) <br /> r PUMP&WALL ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> i Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/orinstalltheworkhereindescribed-This application l5 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Laces ealth"District. <br /> 1 City/Town <br /> Exact Site Address :0 <br /> /_ _ Phone <br /> Owner's Name ( � city- <br /> Address <br /> ity <br />! Address . >� Business Phone <br /> License# /' <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> JLHD? Yes 1< <br /> Is Certificate of Workman's Compensation atInsurance <br /> on FE ❑ile It SRECONDITION 11DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> .-Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> E] INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing <br /> I I9 DOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC -13DRIVEN <br /> 11 GRAVELPACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> k ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION <br /> ❑ DISPOSAL <br /> 13 OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal d By: W <br /> t <br /> tracor l <br /> I PUMP INSTALLATION: Con ,R� H P, <br /> Typeof Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR'y.t- M State Work Done }" <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> r Describe Material and Procedure <br /> I hereby Certify that I fiave 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 /> L is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> j 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 to workman's compensation laws of California." <br /> I ill call.for a Gro do o jgrou ' and a final inspection. <br /> jyt/ itle: Date: <br /> Signed (Draw Plot Ian on Reverse Side) <br /> FOR PARTME T USE ONLY <br /> PHASE I Date l <br /> Application Accepted By <br /> Additional Comments: pe t F'naI inspection <br /> Phase 11 Grout Inspection Date 6-Z,1-6b <br /> Inspection By <br /> Date Inspection By a <br /> ❑ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> Fee IS Due: ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> r - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER r <br /> OTHER <br /> 445- <br /> Received by Date <br /> Receipt No. r [ 1 suanc Date Mailed Delivered <br /> 16D7 E.HAZELTON AVE.,P.O.Box 2009 570CKTON,CA 95201 <br /> ,. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />