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ApplicationsWill Be Processed When Submitted Properly Completed. Be Surly S" el ,- 11 Mon.0 <br /> FOR P FFICE USE: APPLICATION hU �_ — <br /> APR <br /> i _ t <br /> (For Non-Transferable, Revocable, Suspendable) R 9 1 8? <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WALL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JO QUIN LOCAL <br /> EALTApplication is hereby madetothe San Joaquin Local Health Districtfora permit-to construct and/or install thewokkheren esccribdl.�This application is I <br /> made in compliance with San Joaquin County Ordina ce N 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> r <br /> Exact Site Address t ,' `s j City/Town L ' <br /> Owner's Name LN <br /> Phone <br /> Address <br /> Contractor's Name A '3 City <br /> b License#J� 7 Business Phone v f 3 �' _ <br /> Contractor's XGI5�pC _ lsL ��, Emergency Phone r <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4=MwTn-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMPREPAIRL� <br /> REPLACEMENT S - <br /> DISTANCE TO NEAREST: Septic Tank J0 c, Sewer Lines _ /00 _ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ; I <br /> INTENDED USE TYPE OF WELL k <br /> INDUSTRIAL © CABLE TOOL bia. of Well Excavation s 1 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑,DRIVEN <br /> Gauge of Casing <br /> ❑ IRRIGATION K,0RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 14 State Work Done ,-." "-Z,4- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 for which this N <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Got Inspection prior to grouting and a final inspection. <br /> Signed X -dL)� Title: rt" <br /> Date: `L t <br /> (Draw Plot Plan on Reverse Side) <br /> ^I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date w� "t <br /> `—N-Irl <br /> Additional Comments: <br /> Phase fl Grout Inspection Ph III Final Inspection ' <br /> Inspection By Date Inspection By Date s <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ; <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER, <br /> Received by Date Receipt No. Permit No. lqgKance Date �do) livered - <br /> APPLICANT—RETURN ALL COPIES TO:r ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Bac 2009 STOCKTON,CA 95201 <br />