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Applications WIII Be Processed When Submitted ProperlyCompleted.BeSure iosign inemppiisaian+ <br /> FOR OFFICE USE: / I APPLICATION <br /> or Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t�<f� ATER QUALITY <br /> (COMPLETE IN TRIPLICATE < � S, �/el�� �J� <br /> Application is hereby made to the San��oaquinLocaHealthDistrlc orapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis l <br /> ' County Ordin�ce NO. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> made in compliance with an Joaqut <br /> 3 <br /> 111 <br /> Exact Site Address .I <br /> City/Town <br /> Phone <br /> Owner's Name '(A <br /> City <br /> Address �2 'fir �_ c,��.i~ <br /> Ii License# _�!Sl Business Phone <br /> Contractor's Name <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman'sComperisation Insurance on File With SJLHD? Yes_ <br /> No �] t <br /> TYPE OF WORK (CHECK): NEW�WELL� DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> IR C1 <br /> WELL CHLORINATION 11WELL ABANDONMENT 11OTHER 11PUMP INSTALLATION 13PUMP REPA <br /> REPLACEMENT❑ f 1 TC 4 <br /> DISTANCE TO NEAREST: SeptJ Tank 1174 +A Sewer Lines�:�Q -1, Pit Privy uul t <br /> f Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Prop ertyLine /D��[ Private Domestic Well_ _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL Q CABLE TOOL Dia. of Well Excavation ti <br /> 11DOMESTIC/PRIVATE DRILLED Dia. of Well Casing t <br /> i ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing ... 4 <br /> IRRIGATION 1:1GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I <br /> C1 GEOPHYSICAL ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> - PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth 1 <br /> I 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,land rules and regulations of the San Joaquin Local Health District. <br /> :"I certify that in the performance of the work for which <br /> Home owner or licensed agent's signature certifies the followingthis 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 t11is <br /> permit is issued, I shall`employ persons subject to workman's compensation laws of California." <br /> I will call for a Gr 1 I I ect' riot to grouting and a final inspection. <br /> I Title: Date: <br /> Signed X II ( <br /> Draw Plot Plan on Reverse <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> I ; <br /> + Application Accepted By f <br /> Additional Comments: �! <br /> sP a Ili Fina nspection <br /> Phase II Grout Inspection <br /> Data/_ <br /> Inspection By <br /> !I1I Date Inspection B <br /> +' Fee IS Due: ❑ ANNUALLY ' ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By J uary 31 ❑ July 1 &Receiv d By REMITuly 31 <br /> BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASET EXPLANATION DATE DATE REMITTED AMOUNT <br /> I <br /> r FEE <br /> LESS <br /> PRORATION iIt <br /> PLUS :II <br /> PENALTY ! .. <br /> I <br /> 4 OTHER II <br /> f OTHER II� <br /> Date Receipt No. Permit No, Issuance Da a Mailed Delivered <br /> Received by E ' <br /> { 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261` <br /> -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYlCES .r <br /> . II <br />