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P yCompleted. .,.` rr.. <br /> Applications Will Be Processed When Submitted Properly <br /> � <br /> 4OFFICE USE: <br /> {For No Transferable,Revocable,Suspendable} PUMP&WELL <br /> rR <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY - s application is <br /> (COMPLETE IN TRIPLICATE) uin <br /> Application is hereby madetotheSaJoaq Count LOrd+Hancocal e Do t1862 a drictfora phe rutocand regulattiions oftthe S n Joaquin+Local Health District. <br /> made in compliance with San JoaquinY <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name --� City <br /> Address License "-S— <br /> Business Phone <br /> Contractor's Name Emergency Phone 2 2 <br /> Contractor's Address No <br /> Yes <br /> is Certificate of Workman's Compensation Insurance on File❑With SLNCpNDI ION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL CDEEPEN '&-PUMP REPAIR❑ LAI <br /> WELL CHLORINATION ElWELL ABANDONMENT ❑ OTHER ❑ < PUMP INSTALLATION P <br /> REPLACEMENT❑ _ Pit Privy <br /> BOG Sewer tines� r <br /> DISTANCE TO NEAREST: Septic Tank O <br /> Sewage Dispos I ipld �/£ '�` - Cesspool/Seepage Pit Other <br /> Property Line —Private Domestic Well ��/ Public Domestic Well <br /> �1 ` r <br /> YPE OF WELL <br /> INTENDED USE Ta + <br /> 13 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED � Dia. of We11 Casing1:2� r� { <br /> ®DOMESTIC/PRIVATE P* <br /> ❑ DRIVEN 4` .Gauge of Casing <br /> ❑ DOMESTIC/PUBLIG <br /> ❑ GRAVEL PACK Depth of Grout Seal C <br /> Y ❑ IRRIGATION GARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information j <br /> 11 DISPOSAL 11 OTHER s <br /> � �`'• � Surface Seal Install By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P, <br /> Type of Pump �� 9 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> 11 State Work Done <br /> C Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter ! <br /> Describe Material nd Procedure ordance with San Joaquin County <br /> �f a <br /> 4:7 Y <br /> I hereby certify that I have prepared this application and that the work will be done in acc <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> r Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> h 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 /> j permit is issued, I shall employ persons subject to workman's compenalsation laws of California." <br /> IW <br /> �ili cr a Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: <br /> Signed X - (Draw Plot Plan on Reverse Side) <br /> 1 <br /> F DEPARTMENT USE ONLY / <br /> r PHASE I <br /> � Dat <br /> ` Application Accepted By <br /> Additionalomments: Ph a III Final inspection <br /> Phase II Grout Inspection toLill <br /> Inspeckio ,By <br /> Date inspection By <br /> y, PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> - Fee is Due: 13 ANNUALLY ❑ REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> .+� BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> { FEE <br /> 6 - - <br /> LESS: <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER _ F <br /> OTHER <br /> a Perm't No. Mance Mailed Delivere <br /> Received by Date Receipt No. <br /> 1601 E.HAZELTON.AVE.,Ill Box 2009 5TOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />