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Applications W€H•Be Processed When Submitted Properly ComplejeW 91&1�T"i4ATIJe LgIIIT' <br /> FOR OFFICE USE: APPLICATION _ �! <br /> *F (For Non-Transferable, Revocable,Suspendabl®EC 0 1979 <br /> J l J PUMP&WELL <br /> k ENVIRONMENTAL HEALTH PE IT <br /> t WATER QUALITY JOAQUIN LOCAL W <br /> I (COMPLETE IN TRIPLICATE) j..f u p � <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstruct and/or lnsa t ��escribed.Thisapplication is <br /> Pplicationis <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and ttfhe rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �8 � � {��JV/IJA 1u R d. City/Town e sge 4�dit/ <br /> 4 Owner's Name Phone <br /> I Address t City 64C,094 /v <br /> Contractor's Name J9. St., License Business Phone 8,?8—R_.?0 7 <br /> Contractor's Address -2063 /161 /hl Emergency Phone _ —4-ar <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN El RECONDITI ON <br /> ❑ DESTRUCTION❑ <br /> l WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPA€RIV <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> c <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK depth'of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 1. Q <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. 611, 16 H.P. <br /> F 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 <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 <br /> i 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout In ction nor to grouting and a final inspec' r <br /> Signed X Title: Date: 9.2 <br /> (Draw Plot Plan on Reverse Side) <br /> F R DE ARTMENT, SE ONLY <br /> f PHASE <br /> Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout Inspection P�Final ction <br /> Inspection By Date ll� Inspection Bate 2 <br /> kFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recewed�By July 31 { <br /> I REMIT <br /> BILLING REMITTANCE $ <br /> BASE 'EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> f AMOUNT <br /> ' FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> f PENALTY - <br /> OTHER <br /> OTHER <br /> / la �� 1 to as 33�� <br /> Received by foate Receipt No, Permil No. Issuance Date Mailed Delivered <br /> �' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC A 95201 <br />