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Applications Will Be Processed When Submitted Properly L;omplelea. oe aurc IV--I$* •••�^*r <br /> FOR OFFICE USt; APPLICATION <br /> 3' (For Non-Transferable, Revocable, Suspendable) pUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit 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 LTar�I Health District. <br /> Exact Site Address/47 4-S City/Town. <br /> ity/Town •r <br /> �� �9 <br /> Phone <br /> Owner's Name <br /> Address <br /> •2nvct,- S City <br /> License# Business Phone <br /> Contractor's Name <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> No y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �� I <br /> REPLACEMENT❑_ <br /> DISTANCE TO NEAREST: Septic Tank Sewer.Lines Pit Privy <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 <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION p ❑"GRAVEL PACK 4 Depth of Grout Seal <br /> i ElCATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL <br /> 13 OTHER Other Information <br /> ❑ GEOPHYSICAL _ - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor__ H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: 0 State Work Done <br /> Work Done Wor <br /> PUMP REPAIR: ^^ . . ❑ 'State / <br /> Approximate Depth — <br /> DESTRUCTION OF WELL: Well Diameter ,,k <br /> Describe Material and Procedure r r <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County v <br /> ordinance's, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> it <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perm <br /> is issued, I shall not employ any person in such manner as to become subject to workman's'compensation laws of California." <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws'of.California." <br /> I will call for a Grout Inspection pno to grouting and a final inspection. <br /> k T.Itle: _ ��� Date: <br /> Signed /C� <br /> ( w PI Ian an Reverse'Side) <br /> i FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE[ Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final inspection <br /> Inspection By Date <br /> •-- Inspection By Date 01-4 -%Z� <br /> ❑ PER UNIT El PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received <br /> By July 31 <br /> Fee Is Due: ❑ ANNUALLY <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION HATE DATE REMITTED AMOUNT. <br /> FEE <br /> N0 a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> ate � Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 sTOCKTON,CA 9520 <br /> Received by <br />