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.. <br /> Applications Will Be Processed When SUbMitted Properly o <br /> FOR OFFICE use: APPLICATION <br /> �o�� <br /> ^1,k, — fi, {For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> U -j,. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY cribed.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des <br /> I made in compliance with San Jo quin County Ord' a No. 1f3 2 and the rules and regulations of the San Joaquin c I Health District. <br /> City/Town <br /> r <br /> Exact Site Address <br /> , � <br /> Owner's Name k r Phone ' <br /> City <br /> Address r � <br /> j /93-74d—Business � t 7A <br /> Contractor's Name License# Phone, <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance-on File th SJLHD? Yes _— <br /> No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> i <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 ' OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> k ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r 91 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> k <br /> ❑ IRRIGATION 1:1 GRAVELPACK Depth of Grout Seal <br /> 13CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL 11 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done ; <br /> PUMP REPAIR: ❑ State Work Donee <br /> I Approximate Depth <br /> DESTRUCTION OF WELL: 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 /> ... <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 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 /> permit is issued, I shall employ persons subject to.workman's compensation laws of California." Y <br /> F I w'i call for aGrout Inge do p r- gro ng�and a final inspection. - <br /> Signed X <br /> / itle: —_-F. Date: <br /> (Draw Plot tan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Illi Date `�" <br /> 4, <br /> Application Accepted By <br /> Additional Comments: <br /> �111 Grout Inspection Phase II Final inspection <br /> Phasepy <br /> i !v Date Inspection By <br /> inspection By <br /> d By <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EAGH ' El January 1 &Received By January 31 ❑ Juiy 1 &Receiv REMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE` $ AMOUNT buE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> f <br /> FEE S.._C'i <br /> u: <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. <br /> APPLICANT=RETURN ALL COPIES <br /> TO:: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 160Y E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA'45 <br />