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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) PUMP&W <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> r <br /> (COVPLETE IN TRIPLICATE) WATER QUALITY <br /> Application <br /> lsherebymadetotheSanJoaquinLocalHeaRhDistrictforapermittoconstructand/arinstalitheworkhereindescribed.Thisapplicationis i <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address r City/Town _ S oc.�: oAZ <br /> Owner's Name 4f 14 9d It C IC 5, Phone <br /> Address " City ' a C7 , <br /> Contractor's Name -141 icense#"Z?? 11 y Business Phone{ <br /> Contractor's Address '_` Emergency Phone <br /> h <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes es No 01 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank ewer Lines Pit Privy — <br /> Sewage Disposal Field—Me)— Cesspool/Seepage Pit Other t I <br /> Property Line Private Domestic Well.!�a(-E- Public Domestic Well ----�.__ <br /> INTENDED USE TYPE OF WELL <br /> r. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 r <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal s <br /> ❑ CATHODIC PROTECTION JWROTARY Type of Grout C E ti i ICAr f ,.... <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done {/1 <br /> DESTRUCTION OF WELL: Well Diameter 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 rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's 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 /> 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 , rsons subject to workman's compensation laws of California." <br /> ilt <br /> I wall for a rotrt�lnspe"ti prior to grouting and a final inspection. I <br /> Signed _ Title: ! r•r Dater <br /> I (Draw Plot Plan on Reverld Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI / <br /> Application Accepted By ��-t'tiL- - Date <br /> Additional Comments: <br /> - P ase II Grout Inspection r hese III Final Inspection �/ <br /> Inspection By Date �rZc�r 1 Inspection By Date rL7 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING- REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L // f� <br /> LESS �C V <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by .DateReceipt No.-- Permit No. IS&uancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- --ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />