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n Applications Will Be Processed When Submitted ProperlyCom ejpa4gn gigPF't" 'S�" <br /> FOR OFFICE USE: APPLICATIQI�- z� <br /> (For Non=Transferable, Revocable,S dable)O� �� pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMI� I_0CA1_ ; <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY TRIC� <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstructd ortan �UNCoI ereindescribed.Thisapplicationis <br /> made in compliance with n Joaquin County ordinance No. 18 2 and he rules and regulations of the Sari J gain Lo I Health District. <br /> Exact Site Addresses• City/Town ; <br /> _! Phone <br /> Owner's Name <br /> Address 0 City �I <br /> �L <br /> Contractor's Name License# Business Phone �� <br /> P Emergency Phone <br /> Contractor's Addressc <br /> Is Certificate of Workman's Compensation Insurance on File With SRECO YesNDITION C1 DESTRUCTION 13TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALIzATION14 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 0- <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 i <br /> ❑ DISPOSAL ❑ OTHER Other information 4 <br /> ❑ e Seal Installed By: <br /> GEOPHYSICAL Surfac <br />` PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of dump <br /> . <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter J <br /> I 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 /> 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 work man'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 /> F permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k I will call for a Grout Inspection prior to grouting and a final inspection. <br /> l� <br /> Date: <br /> Signed X Title:. F <br /> F (Draw Plot Plan on Reverse Si e) <br /> k OR D PARTME USE ONLY <br /> ! a <br /> PHASE I # / / <br /> Date <br /> Application Accepted By <br /> Additional Comments: }, <br /> Phase II Grout Inspection Phe III Fin Iinspectae <br /> Inspection By <br /> Date Inspection By Date <br /> 'I <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> k ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I I <br /> FEE ), I <br /> LESS I i <br /> PRORATION ' t <br /> PLUS f <br /> PENALTY I 11 <br /> 1 , <br /> OTHER <br /> r `OTHER <br /> 2 <br /> Received by <br /> Date Receipt N. Permit No. Issu nce to Mailed - O ivered <br /> Q APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERV�./,/W_f 11601 E.HAZELTON AVE.,P.O.BO%'2009 STOCKTON CA 95 �' <br />