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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFdCE USE: APPLICATION i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT n `/. <br /> WATER QUALITY A P/v c 3q r t~O-D� <br /> (COMPLETE IN TRIPLICATE) ., J <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit4 San Joaquin County Ordinancg No. 1862 and the rules and regulations of the San Jo uin Local Health District. <br /> Exact Site Addresszll/o City/Town rr A710 N( <br /> Owner's Name 11 Phone ? — <br /> Address ►.- ..T City <br /> Contractor's Name Al�KG License#�3�I1 y'-.- Business Phone_ <br /> 5'i--.2frio ' <br /> Contractor's Address s ! Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ _�� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLATION D PUMP REPAIR❑ <br /> REPLACEMENT 0 / t k T <br /> DISTANCE TO NEAREST: Septic Tank JO J, Sewer Lines Pit Privy <br /> - Sewage Disposal fjeld + Cesspool/Seepage Pit Other <br /> Property Line Private Private Domestic Well Public Domestic Well �~ <br /> INTENDED USE TYPE OF WELL ti <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation U i <br /> DOMESTIC/PRIVATE ❑ DRILLED r' Dia. of Well Casing <br /> DOMESTIC/PUBLIC T - ❑ DRIVEN Gauge of Casing 1 v <br /> ❑ IRRIGATIONr <br /> ' K GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout es _ <br /> ❑ DISPOSAL. ❑ OTHER Other Information —' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: .,,k I_�lils <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit a <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 y <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." r <br /> a <br /> 1 will tali for a o nspe o rior to grouting and a final inspection. <br /> Signed X Title: _ ,pf s+c - Date: IL. <br /> (Draw Plot Plan on Revers Side) ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i ��• <br /> Application Accepted'By pate <br /> Additional Comments: <br /> Phase II Grout Inspection ] Phase III Final Inspection w <br /> Inspection By \ Date ] Inspection By Ufl Date �k j <br /> Fee IS Due. 11 ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING 'REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $43 ckrk <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> { <br /> OTHER <br /> C) s <br /> Received by Date Receipt No. Permit No, - suan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERV <br /> ICES 1601 E.HAMILTON AVE.,P.O.Box 21709 STOCKTON,GA 4520 <br />