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ApplicatlonsWilI"Be ProzSued Properly Completed. Be Sure To Sign The Application. t <br /> FOR OFFICE USE: LIGATION <br /> f (For Non-Tra ble, Revocable, Suspendable) <br /> LS / <br /> c�I1��NMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) j, ^� ATER QUALITY <br /> Application is hereby made to the San Joaquin LocyJ` 4 DIf r a permit to construct and/or install the work eindescribed.This application is <br /> made in compliance w' h S n Jo uin r t ala. a d e es and re loft ns �f the San J o e th istrict. <br /> Exact Site Addr CIty/Town <br /> w a <br /> AOdX1 Phone .c� <br /> City <br /> Contractor' Name License Busli s Phone <br /> Contractor's Address Emergency Phone u <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? Yes f'J No r, <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E -- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i Property Line Private Domestic Well Public Domestic Well <br /> i (INTENDED USE- ,.� . TYPE OF-WELL---- -- <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ~ <br /> I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well'Casing <br /> f ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN I Gauge of Casing <br /> ❑ IRRIGATION �-GRAVEL'PACK-'-; Depth of Grout Seal <br /> ❑ CATHO.DIC.,.PROTECTION ❑ ROTARY. 3 a Type of Grout <br /> ❑ DISPOSAL- ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t <br /> • • Type of Pump ` H.P. <br /> PUMP REPLACEMENT: ate Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> ! Describe Material and Procedure <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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit W <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 hi ' or sub-contracting signature certifies the foliowin certify,that in the performance of the work for which this <br /> permi is d, I shall a ersons subject to workman's cam sation laws of California." <br /> ,ut�Innspe/do prior to grouting and a final ins ct' nA-. <br /> Signed X. C✓/�/rte T e: � <br /> -- -_ _ Date: <br /> .. <br /> (Draw Plot.. n on Reverse Side) - <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By `t5 � <br /> Date <br /> Additional Comments: :l <br /> Phase II Grout Inspection Phase III Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REWT <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> i <br /> LESS 14 <br /> r PRORATION <br /> f PLUS - <br /> PENALTY s _ <br /> OTHER <br /> OTHER <br /> Received by Date :� Receipt No. Permit No.- Issuance Date - Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> Z-4 .1 1 , <br />