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Applications Will B'e Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> FOR OFFICE USE: I APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> j'_ C�r+.t TER QUALITY 7J-�4�= '0 Z <br /> (COMPLETE IN TRIPLICATE)-rQ�gcC.3� ��t-.� Q �I r`'-3��`" j-� <br /> Application is hereby madeto the San Joaqui n Local Health Districtfor a permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaq g ount Ordinance No. 1_8662/jnd he rules and regulations of the San Joa in Loc Health District. <br /> Exact Site Address '^1 .� t 'trr City/Town <br /> Owner's Name I 'A4,-) i���0 Phone - <br /> Fr'h <br /> Address City ' a <br /> Contractor's Name iM icense#i;,S22fil)-3 Business Phone '! <br /> Contractor's Address �� 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❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ (I� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines -Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> ,i <br /> Property Line Private Domestic Well Public Domestic Well <br /> s <br /> INTENDED USE TYPE OF WELL /,, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL t Dia. of Well Excavation <br /> DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC j ❑ DRIVEN ; Gauge of Casing C <br /> I <br /> ElIRRIGATION ❑ GRAVEL PACK x Depth of Grout Seal .5 _ I, r. <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information / f <br /> ❑ GEOPHYSICAL Surface Seal Installed By: hr4�^Sr�2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done f <br /> DESTRUCTION OF WELL: Well Diameter 3 Approximate Depth <br /> Describe Material and Procedure <br /> 6 - <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 runes and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agents signature certifies the following:"I certify that in the performance of 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 /> L-q <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 ' sue , i shall empld�y persons subject to workman's compensation laws of California." ,r <br /> I will cal r Grout nspe tion prtor to grouting and a final inspection. <br /> Signed X Title: Date: , <br /> 1� (Draw Plot Plan on Reverse Side) �v <br /> I FOR DEPARTMENT USE ONLY <br /> F. e <br /> ' PHASEI <br /> Application Accepted By I Date <br /> Additional Comments: iM <br /> Phase 11 Grout Inspection Phase III Final inspection <br /> j <br /> Inspection By rt� Date Inspection By Date <br /> y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER/UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> k ; BASE ii� EXPLANATION ! BILLING ? REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED C�'z AMOUNT <br /> FEE •3 kALLJ1 T /J <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> � f <br /> OTHER <br /> OTHER II <br /> 1 <br /> -711AIL? '1166's <br /> _Received by Date 1I -Receipt No + .'Permit No. - - ssuance Date " Mailed Delivered4CzVi_,;/APPLICANT—RETURN ALL COPIES TO:tl ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Sox 2009, 5TOCKT0N <br />