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ApplicationsWill Be Processed When Submitted Properly Complete' .Be ie I I- ;": I-- I�, e 1 -" .- <br /> P Y P �S�ere,To_SIgATh Applic too '. ~ <br /> FOR OFFICE USE: I APPLICATION 1 '' <br /> (For Non-Transferable, Revocable, SusLUJ <br /> edable r °' ? r <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,°,� ,€ "°: , LOCA <br /> Appl ication is hereby made to the San Joaqui n Local Health District for a permit to construct and/ i1t_alliiaeTvi3rkh)eelri described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San igafluin Loc Health District. i <br /> Exact Site Address City/Town 6 <br /> r <br /> Owner's Name S /Vs <br /> o <br /> ��I Phne (G <br /> Address l <br /> Contractor's Name 1 G City <br /> �' License# 3j4�5- Business Phone_sj 3 <br /> Contractor's Address 6! F6— Emergency Phone k <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL C] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I1,� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ �1` <br /> REPLACEMENT❑ N W WS-4 ^ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy lXl <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout p. <br /> ❑ DISPOSAL ❑ OTHER Other Information . <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work-Done-- - <br /> PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 rulesiand 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 M <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 for which this t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." p <br /> I will ca r a Gr Inspection <br /> Ii <br /> r.to routing and a final inspecilo <br /> Signed X Title: _ V Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � <br /> Date L �^� <br /> Additional Comments: T <br /> Phase II Grout Inspection h III Final Inspection 1 <br /> Inspection By Date Inspection B Date <br /> -r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &R <br /> eceived By January 31 ❑ July 1 &Received By July 31 <br /> BASEFX LANATION " BILLING REMITTANCE $ tAMOUNT <br /> REMIT <br /> h, DATE CHECKED <br /> T DATE REMITTEDAMOUNT <br /> FEE LESSPRORATIONPLUS <br /> PENALTY <br /> OTHER + I <br /> }f F <br /> OTHER 11 <br /> •Received by Date Receipt No. Permit No. Issuance Date -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES_ i 9601-E.HAZELTON AVE.,P.O.BOY 2009 STOGKTON,-CA95201 <br /> g. - <br />