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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.. <br /> FOR OFFICE USE: APPLICATION <br /> o� <br /> �d'+'�e l {For Non-Transferable Revocable Sus�' ' P endable <br /> ) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY * - <br /> ApplicalionisherebymadetotheSanJoaquinLocalHealthDistrictfo a permit to construct and/or install thework.herein described.This applicationis <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 <br /> City/Town <br /> Owner's Name - 71 r <br /> Phone . F <br /> Address ° 'Cez.1 m <br /> - City ` <br /> Contractor's Name "''License# /95 731.E Business'Phone d <br /> Contractor's Address &24 ` ' A� " Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fiie W SJLFi Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ "RECONDITION❑ DESTRUCTION[] - <br /> WELL <br /> ESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ li <br /> DISTANCE TO NEAREST: Septic Tank Sewer,Lines� Pit Privy <br /> Sewage Disposal Field- iF Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL ! <br /> Dia. of Well Excavation - . <br /> 00 DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY f Type of Grout <br /> ❑ DISPOSAL ❑ OTHER ! Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installe By:. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H. <br /> i PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done lie <br /> DESTRUCTION OF WELL: Well Diameter �� ? Approximate Depth <br /> Describe Material and Procedure <br /> it � <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 /> !-tome owner pr 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." <br /> Iwill all for a Grout Inspe io pr' r b gro ng and a final Inspection. <br /> Signed ,atm i �F <br /> G itle: Date: <br /> (Draw Plo PIa4 on Reverse Side) <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> PF#ASE l I X <br /> Application Accepted By � .�. Date <br /> Additional Comments: �� <br /> Phase fl Grout Inspection ; Phase til Final Inspection <br /> Inspection By Date Inspection By 1- Date <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑'July 1 &Received By July 31 <br /> BILLING-1 REMITTANCE $ REMIT { <br /> i BASE EXPLANATION DATE i- DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE j „C <br /> LESS �I ��] <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> • R <br /> Received by Date Receipt No. &Pere it No, Iss ante ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM IT1SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 ST06KTON,CA 95201 <br />