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.� � . <br /> Applications Will Be Processed When Submitted Properly Completed. BSureTobign vneAppelicallull. q <br /> r. APPLICATION <br /> IA <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,5uspendable] PUMP&WELL <br /> x ENVIRONMENTAL HEALTH PERMIT ` <br /> PAA <br /> (COMPLETE E,.-TRIPLICATE) <br /> WATER QUALITY <br /> —I <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in""ompliance ith San Joaquin County Ordinance o.186 the.rules and regulations oftt�San Jo�uin oc Health District. <br /> tl�/-�o..--wl1n <br /> Exact Site Address 10 �'� I <br /> Phone I <br /> Owne'r's N eg�- <br /> Address City ��e f {� <br /> Contractor's Name <br /> License#e=�Q�3 Business Phone <br /> Contractor's Address -�' ' Emergency Phone <br /> Is Certificate of Workman"s Compensation Insurance on File With SJLHD? Yes 7�- No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑❑ OTHER RECONDITION <br /> ❑ ITI P ❑P DESTRUCTIONO INSTALLAT ON� ',. PUMP REPAIR❑ � A <br /> WELL CHLORINATION ❑ WELL ABANDONMENT�-+ (� 1 <br /> REPLACEMENT❑ ` <br /> �SewerLines —Pit-Privy-al— <br /> DISTANCE <br /> Pit-Privy <br /> DISTANCE TO`NEAREST."^'—rSeptic-Tank "I <br /> Sewage Disposal Field 140 �� Cesspool/Seepage Pit Other <br /> Property Line �/8 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ltT <br /> CABLE TOOL Dia. of.,Well Excavation-1143­ <br /> 0 <br /> xcavation 433 <br /> ❑ INDUSTRIAL =i r' <br /> L_DOMESTIC/PRIVATE DRILLED Dia. of 4XIf <br /> 13 DRIVEN Gauge of Casing ' <br />� © DOMESTiG/PUBLIC- <br /> 1:1 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> 11ROTARY Type of Grout ,,& <br /> ❑ CATHODIC PROTECTION ]� - <br /> ❑ OTHER Other Information <br /> 11 DISPOSAL 1 <br /> ❑ GEOPHYSICAL <br /> Surfa a Seal installed By: 4 <br /> s <br />�- Contractor <br /> . . <br /> PUMP INSTALLATION: _ <br /> 3 4 TYP1 of Pump H.P. <br /> i ;� - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> t - <br /> PUMP REPAIR: , r ❑ State Workr Dome ¢ . 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t . <br /> E Describe Mate and Procedure t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k ordinances,state`laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the t Ilowing:"I certify that in the performahce of theworkfor which this permit <br /> is issued, I shall not employ any person in such ma a has to become subject to workman's:compensation laws of California." <br /> J-Cont ractor's hiring or sub-contracting.signatu re certifies the�oilowing:, l certify-t hat in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subjeACtro workman's compensatiori laws of California." <br /> 4r iP. r <br /> I will c II for a Groinpection prior to grouting and a final inspection.`„it <br /> ' <br /> Signed X <br /> Title; L a(Lr '�� Date: <br /> (Draw Plot Plan ori,Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> _ Application Accepted By_ <br /> Additional Comments: <br /> I �Pt1a II Gr t Inspectionha III:F aI Inspeciian _ <br /> Inspection By Date Inspection By Date <br /> ANNUALLY ❑ PER UNIT PERSITE ❑.EACH. ❑ January 1 &Received By J4fary'31 „ ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ AN REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION <br /> BASE DATE DATE REMITTED. AMOUNT <br /> �vj s 0 <br /> FEE `{ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> d <br /> I OTHER <br /> .Received by <br /> Date Receipt No: Permit No <br /> Issuance' ate? -Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERV10E5 -1601 E.HAZELTON AYE.,'P.O.Box 2U09,' _.3 T ON, A 95201 <br />