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x:. Applications Will Be Processed When Submitted ProperlyCompleted. odeInoSign TheAppllcauon. i� <br /> FOR OFFICE USE: APPLICATION i�tff 1 $1 <br /> I (For Non-Transferable, Revocable, Suspendable) ; <br /> I� PUMP&WELL <br /> j <br /> ENVIRONMENTAL HEALTH PERMIT JSpsI Ir;; 4rMR�� <br /> (COMPLETE IN TRIPLICATE) 1i WATER QUALITY HEALTH D;3 1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin, County Ordinance NP. 1862 a d e rules and regulations of the San Joaquin Local Health District. ' <br /> Exact Site Address Vii. (/Y�� /pLdj� City/Town _ — <br /> �!! 3 , 0 j <br /> Owner's Name II Phone <br /> Address City <br /> Contractor's Name License# 32 �� - Business Phone C2 <br /> Contractor's Address - o Emergency P one <br /> Is Certificate of Workman's Compensation s ance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): . NEW WEL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL A ANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ UJ <br /> DISTANCE TO NEAREST: Septic Tank Sew jr Lines Pit Privy ^~ <br /> I Sewage Disposal Field_fir 7 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE �� TYPE OF WELL <br /> XEMISTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> i <br /> OESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC II ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION i� RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IM 3�ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ii Surface Seal Installed By: <br /> PUMP INSTALLATION: II Contractor <br /> E Type of Pump H.P. <br /> PUMP REPLACEMENT: i` ❑ State Work Done <br /> PUMP REPAIR: A i, ❑ State Work Done <br /> I DESTRUCTION OF WELL: !` Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ! <br /> II <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:"!certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I�wil jor a Grout Ins ec' n prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> Zr <br /> I ( aw Plot Plan on Reverse Side) <br /> i! <br /> d . <br /> 1 FOR DEPARTMENT USE ONLY <br /> Com.PHASE PHASEI a �f <br /> . Application Accepted By -, Date <br /> S Additional Comments: <br /> i <br /> Ph I rout Inspection �+ hase III Fina Inspection <br /> ! Inspection By Date t.Zj rT t Inspection By &-'a Date <br /> 1 !� <br /> If ,I <br /> Fee Is Due'. 1:1ANNUALLY ,i ❑ PER UNIT © PER SITE EACH ElJanuary 1 &Received By January 31 E] July 1 &Received By July 31 <br /> REMIT <br /> fBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION. . DATE DATE REMITTED <br /> AMOUNT <br /> FEE y <br /> ! LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .. <br /> OTHER <br /> OTHER <br /> cl <br /> Received by Date Receipt No. Permit No. Issuance 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 />