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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. ` <br /> *.. <br /> FQAPPLICATION <br /> R OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY" �z,tY4 , <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin +Loc�l Health District. t <br /> Exact Site Addressti fir City/Town ��0�4c. S� � � <br /> - � L <br /> Owner's Name C ` 1Cs_ "� 'ts'+ti1 Phone <br /> Address �-� 'e=" L.i� � C cj City zC k L-vn <br /> Contractor's Name cj License# �a�1i_ Business Phone - <br /> Contractor's Address 4520 ( e_Q. o"st 'Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WI=LL❑ DEEPEN ❑ RECONDITIONS. DESTRUCTION'59 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Ili <br /> DISTANCE TO NEAREST: Septic Tank Sewer-Lines ��Pit.Privy _ } <br /> r .a---,^--Sewage Disposal Fielder �� Cesspool/Seepage Pit _ � � Other y l <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL -4- <br /> ❑CABLE TOOL Dia. of Well Excavation *k <br /> 11 INDUSTRIAL tE] DOMESTIC/PRIVATE ❑ DRILLED ' Dia. of Well Casing <br /> K DOMESTIC/PUBLIC ❑ DRIVEN ' Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - Jr <br /> 11 CATHODIC PROTECTION r ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface_Seal lnstallecl_By: r„ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1:1 State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . L+ - Approximate Depth <br /> Describe Material and P,rocedu e <br /> I hereby certify that I,have prepared this application and that the work will be done i accordance with an Joaquin County w' <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. w. <br /> Home owner 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 workman's compOnsation 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, I shaIl-employ persons subject to workman's compensation laws of California." <br /> I III all-tGr Inspection prior to routing and a final inspectlon. <br /> r <br /> � Title:c� Date: <br /> Signed X <br /> -# (Draw Plot Plan on Reverse Side) .q ^` <br /> ► FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By E '. DatelI �'e <br /> I <br /> Additional Comments: <br /> ;Phase 11 Grout Inspection Kase Ill Final Inspection <br /> 4I f Date <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION <br /> i <br /> L &REM.1 <br /> U <br /> AMyO1U5—NT <br /> �DUE <br /> lT t CCGHGEC <br /> KED <br /> REMITTED Tt AMOUNT <br /> LEE <br /> ESS <br /> PRORATION PLUS <br /> PENALTY <br /> OTHER G� <br /> OTHER <br /> EU <br /> Received 4y Date Receipt No. Permit No. 'Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />