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�i Applications-WIWB"rocessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR-OFFICE-U§E: APPLICATION J <br /> 4 <br /> (For Non-Transferable,Revocable,Suspendable) .� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> -r <br /> (COMPLETE IN TRIPLICATE) rWATER QUALITY <br /> Application is'hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is N <br /> made in compliance with San Joaquin Co�u�ty Ord' JW 1862 d he rules and regulations of the San J aquin Local Health District. v1 <br /> Exact Site Address�'5F-y �� /V• �J�Q / City/Town San <br />{ <br /> Owner's Name Phone <br /> Address • City <br /> Contractor's Name License#�f_ Business Phone-J �Q { <br /> Contractor's Address Emergency Phone <br /> JF <br /> Is Certificate of Workman's Compensation lTuipee on File With SJLHD? Yes C� No <br /> TYPE OF WORK (CHECK): NEW WELL "I f DEEPEN ❑ RECONDITION❑ . DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � Sewer Lines Pit Privy <br />+ Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> 4 INTENDED USE T)�eE OF WELL <br /> �01'� e7)% <br /> IND STRIAE l2 ABLE TOOL Dia. of Well Excavation <br /> ❑ <br /> OMESTIC/PRIVATE 13 DRILLED pia. of Well Casing ii <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Tke <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _�262 _ <br />' ❑ DISPOSAL ❑ OTHER Other Information <br /> r ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. <br /> r PUMP REPLACEMENT: ❑ State Work Done <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 <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 of the work forwhich 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> IF permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Iwill I I r a Grout In p ion rior�to grouting and a final inspec <br /> f, Signed X 44 Title, Date: y� <br /> C (Draw Plot-Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application AcceptedBy Date Q/7 <br /> Additional Comments: ? <br /> Phase II Grout Inspection Pha a III Final Inspect' <br /> 3 d � <br /> i, Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> i <br /> AMOUNT <br /> L FEE j <br /> f LESS <br /> PRORATION <br /> ii PLUS I <br /> -PENALTY 7 <br /> OTHER .l <br />' OTHER <br /> `7 t•ss_ ti <br /> Received by Date Receipt No Permit No. Y Issuance ate Mailed Delivered <br /> w �- -,APPLICANT—RETURN ALL COPIES TO:' -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.0-Box 2009` ST.06KTON,.CA.95201 - - <br />