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- _ •F--. — �-- <br /> Applications Will Be Processed When SuAPPLICATION <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,5uspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f I WATER QUALITY application is <br /> t"� y �Le'althDi ermittoconstructandlorinstallthewarkhereindescrib�d.This <br /> (COMPLETE IN TRIPLICATE) _ r 'uJ �� strictforap / ��Application ishereby made to the San Joaq } <br /> San Joaquin County Ordinance No.7862 and he rules regulations of the San Joaquin'focal Health Di tri <br /> made in compliance with q g <br /> - <br /> Exact Site Address Phone <br /> -p �4City <br /> Owner's Name �F�p �gusiness Phone <br /> Address �� p t� License# � <br /> Emergency <br /> Contractors Name Phone� � No <br /> Contractor's Address N�X!I�{ <br /> ❑ DESTRUCTI01yP� <br /> Is Certificate of Workman's Compensation 4nsurancpeEEP��40 RECONDITION <br /> SJRL CpNDlT10N ❑ PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL► <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> Pit Privy <br /> REPLACEMENT❑ Septic Tank Sewer Lines Other <br /> EST: P Cesspool/Seepage ool/Seepage Pit <br />` DISTANCE TO NEAR C p <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well r <br /> TYPE OF WELL <br /> r <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE JK DRIVEN Gauge of CasintSeal❑ DOMESTIC/PUBLIC <br /> [3 GRAVEL PACK Depth of Grout �em <br /> GIIII <br /> ❑ IRRIGATION WILROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information Q <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> �[ GEOPHYSICAL Contractor <br /> a PUMP INSTALLATION: H.P. <br /> Type of Pump <br /> I ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Ae Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this <br /> les and regulations of the San Joaquin Local Health District. <br /> rtifies the following:"I certify that in the performan <br /> Home owner or licensed agent's signature cece of the for this permit <br /> ordinances, state laws, and ru <br /> l aws of California.", <br /> is issued, 1 shall not employ any person in such manner as to become I cersubjtify f that in compensation l the performance of work forwhich this <br /> Contractor's hiring or sub-contracting signature <br /> ignatu et to twos the f sllow ng:compensation laws of California." <br /> permit is issued, 1 shall employ persons <br /> l I c �IoGroul I specti prior to grouting and a final inspection. 6Y� Date:`,LSigned X (Draw Plot Plan on Reverse Side) !G j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date l <br /> Application Accepted By <br /> F <br /> .I Additional Comments: Phase N Final Inspection � '�J r._..�U <br /> Phase II Grout Inspection Inspection By I Date <br /> Inspection By <br /> Date <br /> 31 <br /> REMIT <br /> Fee is Due: [I ANNUALLY ❑ PER UNIT PER SITE <br /> gILLI EACH REM�7ANCEy t &Rece;ve$d By January 31 AMOUNT JDUE <br /> &ReceiCHECKEDBy y <br /> BASE EXPLANATION DATE <br /> DATE REMITTED AMOUNT <br /> f <br /> i FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s —/7 ` � <br /> Issuance� ate Mailed Delivered <br /> Receipt Na- Permit No- <br /> ' Received by Date 1601 E.HAZEL70N AVE.,P.O.Bol 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />