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Applications Will Beh Processed When Submitted Properly.Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE). I� WATER QUgIlTY„.,. <br /> r yi. <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 Joaquin CountyWinaqcp No. 1862 and the rules and regulations of the San 4Rqui Local Health District. <br /> Exact Site Address 3 X ��'IZA City/Town <br /> Owner's Name Phone. <br /> Address City ;. <br /> 3" Licensel 13 7 Business Phone <br /> Contractor's Name --- 3' <br /> Contractor's Address / _ � F '` T Erriergency Phone - (ao Fr., <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No } <br /> TYPE OF WORK(CHECK): NEW WELL❑' DEEPEN ❑ RECONDITION 1:1 DESTRUCTION❑ 1J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER ❑ PUMP INSTALLATION0 PUMP REPAIR❑ <br /> REPLACEMENT❑ ; <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field R Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic'Well <br /> INTENDED USE ".' TYPE OF WELL <br /> i_rz } " =CABLE TOOL. _.__- Dia. of Well Excavation <br /> 11 -INDUSTRIAL �•-� - -- - I <br /> �D M ST_IC RRIVATE 1❑ 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 <br /> a <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I] GEOPHYSICAL Sur a Seal Installed,By: <br /> J(� .i-', <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump:. k, H.P. <br /> PUMP REPLACEMENT: i❑, State Work Dong <br /> PUMP REPAIR: I, State Work Done <br /> DESTRUCTION OF WELL: Well Diameter_ ^ 's, i Approxirr ate,Depth <br /> Describe Material and ProceLre - - <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 OQhe San Joaquin Local Health District. <br /> .I . <br /> Home owner or licensed agent's signature certifies the`following:A certify that in the performance of the work forwhich 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 /> 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:warkman's compensation laws of California." <br /> 4 - t � <br /> I3wil -c' 1.-tor Grou1 Ins i'i n prior to grou ing-and a-final inspection.. - -- --- -�-x •� � <br /> Signed X tie: � ' Date: <br /> I` (Draw Piot Plan on Revers Side) <br /> El FOR DEPARTMENT USE ONLY <br /> PHA5E I \/7 T \ Date <br /> Application Accepted By I - - <br /> Additional Comments: lM ' <br /> Phase III Final Insecti <br /> Phase 11 Grout Inspection � �P, ' <br /> Inspection By �� Date Inspection By ���� Da e <br /> I�. L <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH TI January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION `BILL'iNG .REMITTANCE �$ � ..AMOUNT DUE CHECKED <br /> jIbATE DATE REMITTED AMOUNT <br /> FEE - � <br /> LESS <br /> PRORATLON <br /> PLUS l #- <br /> PENALTY � - ' Ir <br /> OTHER t <br /> OTHER <br /> Received by Date M1 I 'Receipt No. - Perm N - I uance to Mailed Delivered i <br /> y I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,CA 95201 4 <br /> I �" l <br />