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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> LO`"pf b (For Non-Transfeble, Revocabie; <br /> raSuspendable) <br /> /PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r/ <br /> (COMPLETE IN TRIPLICATE) dtz$q "� C__OWATER QUALITY <br /> Application is hereby made to the San Joaquin Local He'I)tf District fora permit to construct and/ori stall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance leo. f 62 and th rules a regulations of the San Joaquin Local Health District, <br /> Exact Site Address City/Town <br /> Owner's Name r eCo <br /> Address h u Phoned <br /> +�`: , .f City "" • " ,,." ! <br /> Contractor's Name <br /> License# C r3 —rj 2-l ' Business Phone; � <br /> Contractor's Address +� " Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes_� No " 1111 <br /> TYPE OF WORK (CHECK)- * NEW WELL_❑ DEEPEN ❑ -_ <br /> RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ . PUMP REPAIR ID <br /> REPLACEMENT❑ pQ I <br /> DISTANCE TO NEAREST: Septic Tank sewer Lines <br /> es Pit Privy 1" <br /> Sewage Disposal Field" -s-. """Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well f'fl <br /> INTENDED USE TYPE OF WELL 7 ;a <br /> - ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 11 F <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ <br /> DRIVEN Gauge of Casing <br /> IRRIGATION -❑ GRAVEL PACK Depth of Grout Seal <br /> '❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0 r <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ® State Work Done c <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure f <br /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance ofthework forwhich this permit F <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 orsub-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 /> I will call for a Grout Inspect' rio ng and a final inspection. <br /> Signed <br /> itle: *_ Date: .P $"✓ <br /> (Draw Plot an on Reverse Side), <br /> FOR'DEPARTMENT USE ONLY <br /> PHASE _ � . <br /> Application Accepted ByIL Date;27_1 —8—pa <br /> Additional Comments: # <br /> • Phase II Grout Inspection <br /> P las ll l Fi al Inspection} <br /> Inspection By Date <br /> Inspection By Date _ Z 2 7— �Z <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received ByJanuary 31' "' '❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $. REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> n AMOUNT <br /> FEE S /L1'U' L (_.�_ <br /> LESS 1 5 <br /> PRORATION " <br /> PLUS <br /> PENALTY " <br /> OTHER <br /> OTHER <br /> Received byDate "� - _ <br /> Receipt No Permit No. — . Is u nce ate ,Mailed Delivered <br /> APPLYCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZEL70N AVE.,P.Q.Boz 2009 S70CKTON,CA 85201 , <br /> i <br />