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fl- Yy 'il.. 4 " Q <br /> Apps{tionsSV1fi11�Be:-Processed Whe 'Submiited Property Campleied. Be Sure To Sign The pp ca o <br /> FOR OFFIC USE: I � 0 APPLICATION <br /> r Non- r nsferable,Revocable, Suspendable) PUMP&WELL <br /> DE G ENVIRONMENTAL HEALTH PERMIT <br /> „ IIN I OCAL WATER QUALITY* 1 <br /> (COMPLETE IN TRIPLICATE) JAS EQ.,4�� <br /> ApplicationisherebymadetotheSpanJoaq[ikrtLEcC14Ji ltR istrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Chi <br /> made in compliance with San Joaquip County ordinance No. 1862 and the rules and regulations of the San Joocal Health District. � <br /> ca City/Town <br /> Exact Site Address <br /> ,, , <br /> Phone' <br /> Owner's Name City <br /> Address ea <br /> License# B s!ness Phone <br /> Contractor's Name h— <br /> Contractor's Address CZ '#Emergency Phone ` <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN C3RECONDITION❑P INSTALLATION E;-"/PUMP REPAIR❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER C3 PUMP <br /> g <br /> REPLACEMENT❑ t <br /> Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ` Sewer <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> r ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing } <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of..Grout Seal <br /> E] CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout ,a <br /> ❑ DISPOSAL ElOTHER Other Information " <br /> El GEOPHYSICAL ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P <br /> Type Pump r <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure p <br /> 3 ~ <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 /> 3 <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, I shall not employ any person iri 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 for which this <br /> t to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subjec <br /> I will call for a Grout inspection pr i routling a a fine pection. <br /> r' Date: <br /> Signed X <br /> (Draw Plot Plan on everse Side) <br /> Y FOR DEPARTMENT USE ONLY v <br /> PHASE 4 � pate ` 3' <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection a 111 Final Inspeate <br /> Inspection By <br /> Date Inspection By' ate <br /> t ' <br /> ❑ ❑ PER SITE C1 EACH 11 January 1 &Received By January 31 C1 July 1 &ReceivedByJuly 31 <br /> Fee IS DUE: [3 ANNUALLY PER UNIT <br /> iBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` <br /> BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> 19 <br /> FEE, Q r <br /> LESS <br /> r PRORATION - - <br /> PLUS ✓ <br /> -- PENALTY' <br /> ! OTHER <br /> OTHER 13�1l1 <br /> Received by Date Receipt No. <br /> Permit No. Issu nJale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />