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Applications Will Be Processed When.Submitted Properly Comple $e lSit�l#7d:S <br /> APPLICATION !§LyTto A lic1111, <br /> `FOR OFFICE USE: t - ; :.. ��,.- <br /> f� - (For Non-Transferable, Revocable,Sus ble 4 -wk <br /> i AY 26 1981 PUMP&WELL ;�� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> 6WTY SAN ��),0u N LOCAL � <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or r h Kpi-E iGibRi elcribed.Thisapplicationis <br /> 5 made in compliance LilttL San�{Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> t Exact Site.Address ; f ` � <= N 1 `� • �` City/Tow�n/ <br /> Owner's Name F N �- r � � i" i"7Phone <br /> Address —/ •l �f US ..0 N City �* - <br /> Contractor's Nam o � �+ 4 �^�' License#r 3 Business Phone t �' <br /> .. Contractor's Ailgkl& �_-lam c Emergency Phone <br /> Is Certificate of Workman's Compensation.Insurance on File With SJLHD? Yes No <br /> UJ <br /> TYPE OF WORK (CHECK): NEW WELLD' DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ , "'WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank d Sewer Lines Pit Privy <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> W- RIGATION 0-79'RAVEL PACK Depth of Grout Sear - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY . Type of Grout 7!S <br /> ❑ DISPOSAL 11-OTHER Other Information <br /> ❑ GEOPHYSICAL ii Surface Seal I stalled By: <br /> I. PUMP INSTALLATION: Contrac or l� <br /> Type of mp H.P. 1 <br /> 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 /> 3 <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. r. <br /> Signed X Title: Date <br /> (Draw Plot Plan on Reverse Side) <br /> * FOR.DEPARTMENT USE ONLY <br /> PHASE I Cjf+ ���� <br /> -# <br /> si Application Accepted By � Date � <br /> f T Additional Comments: <br /> h II Grout Inspection /� hase 111 2%zecalltlie-a. <br /> Inspection By Date "r Inspection 8y <br /> } ���` <br /> r + <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ElPER SITE 11EACH ❑ January 1 &Received By January 31 -❑ July 1 &Aeceived By Jul;31 <br /> REMIT <br /> f a; B$LLING -REMITTANCE, $BASE EXPLANATION AMOUNT DUE CHECKED <br /> 'DATE DATE REMITTED AMOUNT <br /> I� Vol <br /> 0 <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> F. PLUS <br /> PENALTY ' <br /> OTHER <br /> _c <br /> f <br /> OTHER <br /> . <br /> Received by rem Receipt No. Permit No.. Issuance Date <=-Mai led Delivered- <br /> t <br /> I ...-te r APPLICANT—RETURN ALL COPIES TO:— ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE.;P.O.Bax 2009 570CKTON,CA 35201 <br /> ,� <br />