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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. •v �i ; <br /> FOR OFFICE USE: APPLICATION <br /> For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fdra permit to construct+arid/or install the work'herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 18fi and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address mZ 1 S Z City/Town <br /> Owner's Name = +��+- Phone 4 <br /> Address 'Y e, IRA City' <br /> Contractor's Name E4-0 me License#rt3-7y�Business Phone: . <br /> Contractor's Address Emergency Phone " <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? YesNo <br /> TYPE OF WORK (CHECK):" NEW WELL❑ `DEEPEN ❑ RECONDITION DESTRUCTION❑ —= =^ V i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT'❑ OTHER ❑ .PUMP INSTALLATION Iff PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic°Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0,CABLE TOOL Dia. of Well Excavation <br /> WDOMESTIC/PRIVATE ❑ DRILLED ._ Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC } } ❑ DRIVEN Gauge of Casing ' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑;OTHER Other Information <br /> ❑ GEOPHYSICAL .1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type.of Pump ` H.P. ��✓ <br /> PUMP REPLACEMENT: 0,State Work Done ' <br /> PUMPIREPA! 5`State Work Done 204' <br /> DESTRUCTION OF WELL: Well Diameter l a '1slRpproximateT Depth. <br /> Describe Material and Procedure <br /> hereby certify that 1 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 /> 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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued; I shall employ persons subject to workman's compensation laws of California." <br /> I 'ill call for a Grout Insp tion i r to gro?fng an. .a final inspecti"14 (on�. - r <br /> Signed +t!'F itle: `�ri�sf Date: �p / <br /> (praw PI =Plan on Reverse Side) <br /> `I FOR DEPARTMENT USE ONLY <br /> PHASEAI <br /> Application Accepted By Date ` <br /> Additional Comments: <br /> Phase II Grout Inspection se til Final Ins ection <br /> Inspection By <br /> Date Inspection By Date lci Z <br /> • �• 4T ti <br /> s <br /> ' Fee I5 Due: ❑ ANNUALLY ❑ PER U�1N4T ❑ PER SITE ©EACH.� ❑ January 1 &Received By January 31 ❑ July 1 &Received By July-31 <br /> REMIT <br /> # 'BILLING REMITTANCE _ $ "AMOUNT.DLIE CHECKED <br /> BASE -EXPLANATION, DATE DATE REMITTED <br /> - AMOUNT <br /> FEE <br /> LESS v <br /> PRORATION <br /> PLUS r - <br /> PENALTY <br /> OTHER - <br /> OTHER - - - <br /> Received by Date Receipt No, Permit No. I uance Vate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />