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Applications Will Be Processed•When Submitted Proper yomp e e <br /> o FILE use: APPLICATION <br /> i tf0b�� r (For Non-Transferable, Revocable,5uspendable) PMP&WELL <br /> / ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY v� <br /> Application is hereby made to the San Joaquin Local Health District fora 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 /> },I Exact Site Address �//'}}aU s� City/Town Phone <br /> Owner's Name e"'�f, +� <br /> Address City ,- <br /> f Business Phone <br /> Contractor's Name`. License#( � _ __N y _ <br /> OL " Emergency Phone -*- _ - P �' _^' �'.-."_==F �� <br /> Contractor's Address ' o <br /> ,rt Is Certificate of Workman's Compensation insurance on File With JLHD? Yes �No f— <br /> �TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 15r <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank 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 /> INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE - ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump 777kyl I AI H.P. <br /> r, PUMP REPLACEMENT: ❑ State Work Done <br /> 7 <br /> PUMP REPAIR: <br /> State Work Done vp <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 San71m, in County s <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> t Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I` is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 4' <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> • permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspectionflpri to gro 1• g and a final inspection. <br /> itle: /' Date,. t <br /> Signed X <br /> (praw Plot Ian on-Reverse Side) <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE I _125 — <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection ' Phase III Final In pection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: 11 ANNUALLY [3 ?PIERUNIT El PER SITE EACH ❑ January 1 &Received By January 31 El 1 &Receiu REMITd ByuIy 31 <br /> • L_ BILLING REMITTANCE $' ` AMOUNT DUE CHECKED , <br /> }} <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a / aci <br /> Received by Dale Rece;pt No. - Permit No. suance iDate Mailed Deliverer ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1641 E.HAZELTON AVE.,P.O.Box 2409 TOCKTON,CA 95201,-'- <br /> Y <br />