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R w� ApplicationsWill,Be ProcessedWhen Submitted Properly Completed:Be Sure To Sign The Applical'ion:•- <br /> -FOR OFFIC_E USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with_S Joaquin County Qrtdinai�ce.fVe: 1 62 an_d_the,.rules and-regulations of the�o Local-Health-District.- <br /> Exact Site AddZ'-,- �--. � �^ City/Towa�rr�! O -_C�lctii: ly/- — <br /> Owner's Name Al- Phone <br /> Address i r <br /> City a G <br /> Contractor's Nam f LL erase#3&O 9.4�1 Business Phone <br /> Contractor's Address ergency Phone <br /> s"" 3 <br /> Is Certificate of Workman's Compensation_Insurance.on File With SJLHD? Yes �r No 1 w. <br /> TYPE OF WORK (CHECK): NEW WELL C9,DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 'I�I s <br /> DISTANCE TO NEAREST! Septic Tank in Sewer Lines Pit Privy ---~" <br /> i: <br /> Sewage Disposal Field-17'0 .. Cesspool/Seepage Pit 425Other <br /> Property Line Private Domestic Well -- Public Domestic Well }, <br /> INTENDED USE TYPE OF WELLc <br /> ❑,�,�INDUSTRIAL 13 CABLE TOOL., Dia. of Well Excavation <br /> 2DOMESTIC/PRIVATE ' ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN.- Gauge of Casing / a. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal O _ <br /> ❑ CATHODIC PROTECTIONC�'}O ARY Type of Grout <br /> ❑ DISPOSAL I , ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL. Surface Seal Installed By:lI 1 P <br /> PUMP INSTALLATION: Contractor 92 -- <br /> Type of Pump H.P. Od <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done '-- <br /> DESTRUCTION OF WELL: ! Well Diameter <br /> Approximate Depth <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 <br /> ordinances, state laws, and r ries and regulations of the San Joaquin Local Health District. ' r <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, 1 shalt not employ any person in such manner as to become subject to workman's compensation laws of California.' `� 1 <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,-) shall emp ersons subject to workman's compensation laws of California." <br /> :I. <br /> I w call for a Gr ec n pr r to grouting and a final inspection. <br /> Si r Title: _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By O Date -�� <br /> Additional Comments: <br /> Phase II Grout Inspection P �L ase III Final In ection _. �. <br /> Inspection B Date T 23 Inspection By e <br /> Fee Is Dae: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE IN M>1+�1a 43 <br /> LESS <br /> PRORATION <br /> PLUS II <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DateReceipt No Permit NoM <br /> . Issuance Date ailed Delivered, <br /> APPLICANT—RETL UflN A COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />