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Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � . <br /> TOIg OFFICE USE: APPLICATION <br /> (For Non-Transferabie, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Joaqul n County Ordinance o. 1862 and the rules and regulations of the Sa oaquin Local Health District. I <br /> Exact Site Address S d I :S K y s,_�� N/�C City/Town ws . <br /> Owner's NameAy <br /> Phone" <br /> Cit <br /> Address t y <br /> Contractor's Name t"' - ` Y rtse# !I y Business Phone Q <br /> Contractor's Address Emergency Phon <br /> Y <br /> Is Certificate of Workman's Compensation Insurance on File_ With SJLHD? Yes ` No <br /> TYPE OF WORK (CHECK): 'NEW WELL. DEEPEN ❑' RECONDITION DESTRUCTION[]-' - n T <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑. OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR❑ v 5 i <br /> REPLACEMENT❑_ .!� r r O r <br /> DISTANCE TO NEAREST: Septic Tank %_479:� Sewer Lines csC Pit Privy <br /> Sewage Disposal Disposal Field r Cesspool/Seepage Pit -�- Other <br /> Property Line.-private Domestic Welk . Public Domestic Well # <br /> INTENDED USE TYPE OF WELL € <br /> ❑ INDUSTRIALei <br /> ,,krr`` <br /> D ❑ CABLE TOOL Dia. of Well Excavation y <br /> DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing eowr' - <br /> b DOMESTIC/PUBLIC ! I ❑ DRIVEN Gauge of Casing x <br /> ❑ IRRIGATION I ' GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION kq ROTARY t Type of Grout f <br /> ❑ DISPOSAL OTHER Other information t <br /> ❑ GEOPHYSICAL _ Surface Seal Installed B XL <br /> 1 Y• <br /> PUMP INSTALLATION: Contractor _ _ <br /> Type of Pump H p <br /> PUMP REPLACEMENT: ! ❑ State Work Done <br /> PUMP REPAIR: ' ' ❑ State Work Done t <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth (/} <br /> Describe Material and Procedure i <br /> . - O <br /> I hereby certify that I ha ie prepared this'ailplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, acid rules and regulations of.the San Joaquin Local Health District. <br /> Homeowner or licensed agent's 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 subLontracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons su ject to wor an's compensation laws of California." <br /> I call for a Gra InsplIection p r 10 utin a final inspection. .- _ <br /> Signed X �II" Title: Vrt Date: <br /> (Dr Plot Plan on Revers Side) V 7 <br /> �II FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> 'TSLDate <br /> Application Accepted By� y" <br /> Additional Comments: I� <br /> i <br /> h Grout Inspection" �� P Phase III Final Inspection <br /> Inspection By ni lh -:Date , Inspection By .Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31' ❑ July 1'&Received By July 31 <br /> I� BILLING RENIITTANGE $, REMIT ' <br /> BASE EXPLANATION A AMOUNT DUE CHECKED + <br /> DATE DATE REMITTED AMOUNT <br /> FEEJ 4 14-3 <br /> I LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> s <br /> • a �� 1 - ' � EJ`—V� _ � 11 <br /> Y <br /> Received by Date M� Receipt No Permit No.-= Issuancd Daio - Mailed- - Delivered <br /> APPLICANT—RETURN ALLCOPIES T;p: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />