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_ _ - .. . <br /> „Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> �Q� (For Non-Transferable, Revocable,'Suspendable) �J PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ` <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit toconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin Countyl0rdin ce No.i1862`and the rules and regulations of the San Joaqui Local District. <br /> Exact Site Address_�3 773 t.f in <br /> t/ City/Town <br /> Owner's Name <br /> dhf Phone <br /> 3 7 _ /� �" �: City <br /> Address _ L 4'��0 7 �c <br /> Contractor's Name _` License#: � - '�` Business Phone_ r <br /> '> - v.. <br /> Contractor's Address 'Emergency,Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): - NEW WELL-0 DEEPEN ❑ RE RON❑DiTl4 UMINSTAL ATO ❑❑ PUMP REPAIR❑ <br /> WELL CHLORINATION El WELL ABANDONMENT.13OTHE <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' <br /> Sewage Disposal Field _ - <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> -�' TYPE OF W <br /> INTENDED USE WELL <br /> � <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9_DOMESTIC/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 /> 11 DISPOSAL. []'OTHER <br /> 4 -Other Information <br /> ❑ GEOPHYSICAL . ; Surface Seal Ins ailed By: <br /> PUMP INSTALLATION: Contractor 4L ki <br /> Type of Pump �b H.P. <br /> PUMP REPLACEMENT:ir% Y _'" 13'State Work Done <br /> PUMP�1EfMtIR: <br /> ® State Work Done <br /> DESTRUCTION OF WELL: -T,�r.��'� � �w�� � <br /> Well Diameter ApQroximate Depth <br /> - <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 regulation <br /> the San Joaquin Local Health District. Y w <br /> Home owner or licensed agent's signature certifies the following:' 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, 1 shall employ persons subject to workman's compensation laws of California."± �f <br /> I will call for a Grout.Inspection prior to grouting and a final inspection. ' <br /> Signed X <br /> Title: _- _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY _t I <br /> PHASE I J F Date <br /> Application Accepted B is <br /> Additional Comments: <br /> ! - Phase II Grout Inspection ase III Final inspection <br /> p Inspection By to /li z <br /> Inspection By Date ' <br /> d By <br /> Fee Is Due: ElANNUALLY '❑ PER UNIT ElPER SITE 0 EACH January 1 &Received By January 31 ❑ July i &Receive <br /> REMITuIy 31 <br /> BILLING R TANCE $ AMOUNT DUE CHECKED is <br /> BASE - EXPLANATION DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS °• <br /> PRORATION <br /> PLUS 's <br /> PENALTY <br /> OTHER , <br /> OTHER <br /> �3 C) 5 <br /> Received by _ Date _. Receipt Permit No.. <br /> Issu ce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> \L 1601 E.HAZELTON AVE.,P.O.Bo=2011'3 STOCKTON,CA 95201 <br />