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1 ppicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> FQR OFFICE USE:-- APPLICATION <br /> f - <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to Construct and/or install the work herein described.This application is <br /> made in compliance with San Jo quin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> ! City/Town RY~ C r <br /> I Owner's Name <br /> Al � �c � <br /> Phone _Addressoo <br /> aV - 45 5'1 <br /> C, City <br /> Acv <br /> Contractor's !Name /�/'lYt! ?S 4 l►t License# �o � 6 E <br /> Contractor's Address t /UB Business Phone,_ <br /> Ae' Emergency Phone j <br /> Is Certificate of Workman's Compensation Insu nce on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION,❑ No <br /> DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�-� C3i REPLACEMENT❑ PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines It <br /> Pit Privy -,Al ,0-- <br /> Sewage Disposal Field_ 7 r Cesspool/Seepage Pit-=.N,. g <br /> Property Line ` �_ Other <br /> Private Domestic Well �C�—Public Domestic WellAhv <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> Dia, of Well Casing <br /> JD�DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ { <br /> ROTARY Type of Grout <br /> © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d L <br /> foill 1-% Q <br /> Type of Pump H f ¢ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ' ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter r <br /> 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 Q <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 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: # <br /> "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 ill call for a Gro t Inspection"pri r to grouting and a final insp n <br /> ® 4 <br /> Signed X �f Title <br /> Date: <br /> i (Draw Plot Plan on Reverse Side) is <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By y �� <br /> Additional Comments: Date <br /> Phase Il!Grout Inspection Phase III Final Inspectigrt <br /> Inspection By Date Inspection By 7 r <br /> _ Date <br /> Fee IS Due: 11 ANNUALLY L[!�❑ PER UNIT �}�. <br /> PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &.Received By July,31 <br /> •t <br /> BASE EXP'ANATION BILLING REMITTANCE $ REMIT <br /> 1� DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE tom- AMOUNT <br /> LESS llffpp I �, <br /> PRORATION t <br /> PLUS <br /> PENALTY t ' <br /> OTHER (� <br /> I <br /> OTHER <br /> € II <br /> Received by . . - Date Receipt No� Permit No. <br /> Issuance Date Malted .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> qql�r 1601 E.HAZELTON AVE.,P.O.Box 2009 . ST0CKTO09'Z�V ' <br /> 5201 <br />