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RApplications Will Be Processed When Submlilted Properly Compi6ted.BeSureTo5ign tineAppncuuwlr. <br /> APPLICATION <br /> FOR UFFf' 'USE: - <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ~ ENVIRONMENTAL HEALTH PERMIT <br /> Zi- <br /> 6 WATER QUALITY ••�� <br /> (COMPLETE IN TRIPLICATE} -- stall V' <br /> Application is herebymadetolheSanJoaquinLocalHealthDistrictforapermittoconstructanIons of <br /> Joaquin <br /> calHbed.This.rict.application O } <br /> made in compliance with San Joaquin Count Ordinance No. 62 and the u1 s and regulations of the San Joaquc Locea�Health DistrictD <br /> City/Town 1 <br /> Exact Site Address <br /> Phone 7 x <br /> Owner's Name <br /> City a <br /> Address <br /> II <br /> Business PhonLse <br /> Contractor's Name <br /> Contractor's Address Emergency Phone e <br /> ;t <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIQN❑ DESTRUCTION❑ - <br />" WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> Septic Tank <<n r'� Sewer Lines y <br /> DISTANCE TO NEAREST: <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Fields t <br /> Property Line Private Domestic Welles Public Domestic Well .. <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION 11GRAVEL PACK Depth of Grout Seat r— <br /> ❑ CATHODIC PROTECTION <br /> 1:1 ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> p ❑ GEOPHYSICAL Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump i <br /> PUMP REPLACEMENT: - ❑ State Work Done , , <br /> i PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: - <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f! <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> ompensation laws of California <br /> is issued, I shall not employ any person in such manner as to become subject to workman's cs <br /> ( 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 per ns subject to workman's compensation laws of California." <br /> I will SKI for a Gro n ti 6r grouting and a final inspection. t <br /> " Title: Date: <br /> Signed X ! <br /> (Draw Plot Plan on Reverse U0 <br /> 1 <br /> OR DEPARTMENT USE ONLY O r <br /> jFApplication <br /> ASE I Date/ �' } <br /> �.� . y <br /> Accepted Byditional Comments: <br /> Phase III Final Inspection <br /> Phase If Grout Inspection to � � ' <br /> Date Inspection By <br /> eRZ <br /> Inspection By �')r-7 <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> I Fee IS Due: ❑.ANNUALLY ❑ REMIT <br /> ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �. OTHER <br /> OTHER <br /> r <br /> Receipt No. Permit No Issuance Dale Mailed Delivered - <br /> Received by Date - <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON.CA 95201 , <br /> E APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �` ._ F T <br />