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! Applications'Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE:. APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELD <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is'hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa in ounty Ord' ce No. 1862 and the les pnd regulati n h� Loc ealth DistrI t'. <br /> t� 3 <br /> Exact Site Address 4 1 y own _ <br /> Owner's Name Phone <br /> Address q City <br /> Contractor's Name License#, Q� f,3/.3 Business Pho e — <br /> F <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation urance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank.. t1V Sewer Lines Pit Privy _,�s�1a�-� <br /> I Sewage Disposal F�ld o Cesspool/Seepage Pit "A-E - Other <br /> Property Li rie Private Domestic Well />.?as!1?Public Domestic We11�1��IiIJ <br /> INTENDED USE TYPE OF WELL N <br /> E ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing rp f� Pyu F <br /> ❑ DOMESTIC/PUBLIC ! ❑ DRIVEN Gauge of Casing - <br /> I <br /> El IRRIGATION 1 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION II. ROTARY Type of Grout 0 <br /> ❑ DISPOSAL ! ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r 4 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 1Type of Pump H.P. <br /> PUMP REPLACEMENT: © State Work Done. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Q <br /> Describe Material and Procedure r1.« fLGt l.Lt�s^�� 7a <br /> I hereby certify that I Piave prepared this application and that the work will be done in accordance with San Joagt{Yn Cunt <br /> ordinances,,state laws,land rules and regulations of the San Joaquin Local Health District. <br /> I; <br /> Homeowner or licensed agents 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 compensation laws of California." <br /> f 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 shall employ,persons subject to workman's compensation laws of California." <br /> ,1 <br /> i I will all for a Grout ection rior to grout' and a final inspection. '/ <br /> I ' 7` <br /> Signed X e: Date: <br /> ✓(Draw Plo n on Reverse.Side) _ <br />(' FO EPARTMENT USE ONLY l: .0 <br /> i <br /> PHASE <br />{ Application Accepted By - Dat <br /> Additional Comments: <br /> Phase II Grout Inspection �1� P a III Final I spection <br /> Inspection By Date �In§pection B Dat y� <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER/SITE ❑ EACH ❑ January 1 &Received By January 31 rrI JuVy 1 &Received By July 31 <br /> REMIT <br /> BASE.1 }iEXPLANATION BIDING REMITTANCE $ AMOUNT DUE CHECKED <br /> n ' DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �1 _ <br /> OTHER <br /> tb <br /> e OTHER <br /> < Received by ate Receipt No. Permit No, Is uance ate Mailed Deliveredco <br /> APPLICANT—RETURN ALL COPIES TO 8 ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601,E.HA2ELTON AVE P.04ox 2009 STOCKTON,CA 95201 <br />