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Applicatlons`Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � <br /> FOR OFFICE USE: / <br /> APPLICATION <br /> Op40R (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ._ ,)NATER QUALITY i t t.- �t , r,.-.n _ •. Al t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work-herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address _ � t — City/Yawn <br /> rs f: ' f <br /> I Owner's Name �' Phone_ • � <br /> � <br /> Address 'D. City— <br /> Contractor's Name ` License# ' `Business'Phone Y <br /> * r t t <br /> l Contractor's Address Emergency Pliorie' <br /> Is Certificate of Workman's Compensation Insurance on Fi�WithJLHD? Yes No W <br /> TYPE OF WORK-(CHECK): NEW WELL❑ _ DEEPEN❑' RECONDITION ffroDESTRUCTION❑ L}:J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. `V) <br /> REPLAC€MENT❑ 1, - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property.Line Private D_omestic'Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ; <br /> ❑ INDUSTRIAL © CABLE TOOL t Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . <br /> ❑ IRRIGATION ❑ GRAVELPACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> [3 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION:' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: i = ❑ State Work,Done t <br /> PUMP REPAIR: : 'a ..® State Work Done -7R40 06 <br /> yy ? rApproximate Depth <br /> DESTRUCTION OF WELL: I: /Well Diameter <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 /> Home owner or,licensed agent's signature certifies the following:"I certify that in the performance of thework'forwhichthis 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 /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe n rior wt r utintand a final-inspection. t <br /> Signed Xs <br /> ftle: Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> ' PHASE 1 d ' ` f Date <br /> Application Accepted y <br /> Additional Commen <br /> Phos II Grout Inspection -^��PP�hase III Final Inspection <br /> Inspection By <br /> Date Inspection B.y/K ' — Date �Z Y <br /> d By <br /> Fee IS Due: C] ANNUALLY " ❑ PER UNIT - ❑-PER SITE ❑ EACH ❑ January 1 &Received By January 33"` ❑ July 1 S Recely REMITuIy 31 <br /> 4 - BASE EXPLANATION BILLING .z_REMITTANCE - $ AMOUNT DUE- " CHECKED <br /> DATE DATE. r REMITTED AMOUNT <br /> FEE „ <br /> LESS c <br /> PRORATION <br /> PLUS r .. <br /> PENALTY_ <br /> OTHER <br /> OTHER <br /> "- Delivered <br /> Isuance at Received by Date - Receipt No - +- PermitNo. - <br /> _ Mailed _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 F.HAZELTON AVE.,P.O"Bos 2009 STOCKTON,CA 95201 <br />