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Applications Will Be Processed When Submitted Properly Completed. BSure <br /> FOR OFFIc USE: APPLICATION <br /> (For Non-Transferable,Revocable,5uspendable) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH'PERMIT , <br /> WATIER QUALITY . <br /> (COMPLETE IN TRIPLICATE) �, "- <br /> Application is hereby madetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstallthework.hereindescribed.Thisapplicationis # <br /> made in compliance with San.Joaquin County Drain nce No. 1862 and the r les and regulations of the Sari Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address / p <br /> A. <br /> Owner's Name 1Ti,1v,- drl; 4 City'2' <br /> Address © Business Phone' s` <br /> Contractor's Namea;:nFu4^.' ., - t <br /> Contractor's Address ''r •Emergency Ph6ne <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No _ t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ' <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑. PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ ' pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> -: Cess ooI/Seepage Pit Other <br /> Sewage Disposal Field P <br /> t Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE <br /> " ❑ DRILLED 'Dia. of-Well Casing <br /> ❑ DOMESTIC/PUBLIC O'DRIVEN <br /> Gauge of Casing <br /> 13IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout , <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL -Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type}of Pump V H.P. <br /> ❑ State Work Done J <br /> PUMP REPLACEMENT: t ' <br /> PUMP REPAIR: x ❑ State Work Done <br /> I Approxi mate.Depth <br /> DESTRUCTION OF WELL: Well}Diameter� <br /> f 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 bistrict.._ 1 <br /> Home owner or licensed agent's signature certifies the following:;1 certify that in the performanceof 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 loll owl ng:"I certify that in the performanceof the work for which this fk <br /> fr : <br /> shall employ perso ns subject to workman's compensation laws of California." <br /> permit is'issued;l <br /> will call`lor'arGr ut I apection prior to grouting and a finabinspection.. <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan 6n Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> FApplication <br /> ASEI tem'Da �Accepted Byd-itional Comments: <br /> Phase 11 Grout Inspection Pha a 111 Final Inspection <br /> J <br /> - Inspection By���� Date inspection By r y <br /> 0 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH EI January 1 &Received'By January 31 ❑ July 1 &Received <br /> By Ju4y 31. <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ''BASE EXPLANATION DATE DATE _REMITTED AMOUNT ' <br /> 'i FEE <br /> 4 �.5 <br /> 'LESS <br /> PRORATION <br /> PLUS <br /> i: PENALTY <br /> - •f ` <br /> OTHER • _ <br /> OTHER <br /> Pt <br /> ate Receipt No. +.- _—Permit No. �-» � 'Issuance Date. r Mailed - �-Delivered <br /> Received byAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,EP.O.Box 2004 STOCKTON,GA 95201 <br />