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Applications Will Be Processed When Submitted ProperlyCompleted. BeSureToSign The Application. <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendab. <br /> f PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862andthe rules and regulations of the San Joaquin Local Health District. <br /> Exact Site AddressCity/Town <br /> h; <br /> Owner's NamePhone Z" 3-7' <br /> .Address li' City � o�s <br /> `Contractor's Name icense#:. ' �� � Business Phone /SLG! <br /> "!`Contractor's Address Emergency Phone D '` <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No T <br /> TYPE OF WORK (CHECK): 0 NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ., <br /> WELL CHLORINATION ❑ ': WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR # <br /> REPLACEMENT { <br /> Septic Tank Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: l <br /> a, <br /> Sewage Disposal Field Cesspool/Seepage Pit Other :3, <br /> Property Line Private Domestic Well Public Domestic Well ~" <br /> INTENDED USE I` TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL• Dia. of Well Excavation r� <br /> ❑ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL. Surface Seal Installed By: <br /> PUMP INSTALLATION: I Contractor <br /> Type of Pump HP. <br /> PUMP REPLACEMENT: �: State Work Done_ cr Z MckAi ' br.We A00% .,P4V n.. <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 for which this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." I <br /> Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Iwill call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed / <br /> X r6U 5?// Ja ec-r%J Title: _�, at- � Date: <br /> (Draw Plot Plan on Reverse Side) ► <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i �7 k�� <br /> Application Accepted By �- Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By . Date Inspection By Date p <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED 4 <br /> DATE DATE REMITTED AMOUNT j <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER `I E <br /> "79- 10 3 -- <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered - - <br /> APPLICANT—RETURN AL'L COPIES TOS ENVIRONMENTAL HEALTH PERMITlSERVICES .. 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKY �r $ 41 <br />