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Applications Will Be Processed When Submitted r <br /> APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable, Revocable, Suspendable) pUMP&WELL y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> rules and regulations oft a San Joa in Lo al Health Distric . <br /> tion is hereby madetotheSanJoaquinLocalHealthpistrict#oradp�e ittoconstructand/orinsta44theworkhereinde�scribed�jThisapplicatlonss <br /> Application Ilei'" t Owl4�^ 'E 3�^` <br /> made in compliance wi hZ�Joaquin County Ordinance No.`I�6©�.'l� <br /> Exact Site Address t� / Phone <br /> Owner's Name City <br /> �//,,�� <br /> Address License# � Business Phone <br /> �� <br /> Contractor's Name Emergency Phone <br /> Contractor's Address _ Yes x- No <br /> 1s Certificate of Workman's Compensation insu n DEEPEN With SJRL COI�IDITION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL ❑ PUMP INSTALLATION 13PUMP REPAIR❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT <br /> 13 OTHER � <br /> REPLACEMENT❑ /00 Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage e Pit Other <br /> ol/Seepag <br /> Sewage Disposal Field��- Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE pia. of Well Excavation << <br /> ❑ INDUSTRIAL 13 CABLE 700E 62 <br /> 13 DRILLED Dia. of Well Casing <br /> [V[DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC /GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ROTARY Type of Grout <br /> [I CATHODIC PROTECTION ❑ OTHER Other information <br /> ❑ DISPOSAL Surface Sea! Installed By: <br /> ❑ GEOPHYSICAL s <br /> Contractor H P <br /> PUMP INSTALLATION: Type of Pump <br /> r <br /> ❑ State Work Done <br /> I PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: Approximate Depth <br /> F DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure � <br /> n Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sa <br /> k ealth District, <br /> ordinances, state laws, and rules and regulations of the San Joaquin cert'ifocal thaH n the performance of the work for which this permit <br /> �. Home owner or licensed agent's signature certifies the following:' Y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.' <br /> I g. Y performance <br /> Contractor's hiring or sub-contraCt5ubject to two kman'sllcompensaton lawstof Californaof the work forwhich this <br /> � permit is issued, 1 shall employ persons <br /> r I will If for a Grout.lnspect' n prior to grouting and a final inspection. / <br /> �� pate: <br /> Title: � <br /> Signed (D)w Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted By <br /> Additional Comments: ase 111 Fi I Inspection <br /> ( ase 11 Grout Inspection c Date <br /> Inspection By <br /> ate �U Inspection By - <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ 3uiy 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ <br /> PER UNIT ❑ PER SITE <br /> REMIT <br /> E $ AMOUNT DUE CHECKED <br /> REMITTANCE <br /> I DRILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> .t FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J}Q <br /> O �� Mailed D vered <br /> Date Receipt No. <br /> Permit No. issuance Date <br /> Received'by 1601 E.HAZELTON AVE.,P.O.Boa 2009 570CKTON,CA 952 <br /> 01 <br /> APPLICANT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />