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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> _ PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) -UZ. ATER QUALITY .Z03 -' 1(0— ()J <br /> Application is hereby made to th`e San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is N i <br /> made in compliance��wiit�th,San Joaq in CooUnty Ordinance No. 1$6 and therulesnd regulati .ns of an Joaquin Local Health District. r� <br /> Exact Site Address" $ E ,�YL / `� /T� <br /> Owner's Name ZX0 Phone <br /> 75 Address City f <br /> I Contractor's Name 2 License#,?_?2Z144� Business Phone <br /> Contractor's Address15L S— r�?l�sL" - Emergency PhoneIn <br /> Is Certificate of Workman's Compensation Insurance on FileWithSJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN +4! RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank �.5 r- t: Sewer Lines 4- Pit Privy �- <br /> Sewage Disposal Field 4W If Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL l�of <br /> ❑ INDUSTRIAL CABLE TOOL_ Dia. of Well Excavation__.�7Y �c/ <br /> ❑ DOMESTIC/PRIVATE � <br /> ' ❑ DRILLED Dia. of Well CasingN <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout T% <br /> ❑ DISPOSAL ❑ OTHER Other Information �) <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ALLA C' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done b <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 b <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 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 /> i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fvrwhich this <br /> permit is issued, I shall employ p rsons subject to workman's compensation laws of California." <br /> I wit all for a out I pec prior to grouting and a final inspection. <br /> Signed X Title: _ D� n! Date: <br /> (Draw Plot Plan on Rever Side) <br /> F DEPART ENT USE ONLY <br /> I <br /> PHASE I <br /> Application Accepted y <br /> Additional Comments: <br /> Phalfell Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date 7� Urs'pv <br /> l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1'&Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> j OTHER <br /> k <br /> OTHER <br /> 77 q <br /> Received by Date - Receipt No _ _Permit No Issuance Date Mailed Delivered .t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM T1 ERVICEs 1601-E..HAZELTON AVE.,P.O.Box 2009 SS <br />