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Applications Will Be Processed When Submitted ProperlyCompleted. <br /> APPLICATION <br /> FOR QFFICE OSE: <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL j <br /> ENVIRONMENTAL HEALTH.PERMIT W <br /> ti <br /> WATER QUALITY N <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto San Joa District for a permit to construct and/or install the work herein described.This applicatio;�is � <br /> made in compliance with San Joagi ounty rdi ancM . 1862 an a rules and regulations of the San Joaquin Local Health District. <br /> .7 City/Town <br /> Exact Site Address <br /> M M C, Phone t <br /> Owner's Name ; City <br /> Address <br /> Contractor's Name 1+���� VS CLOS License#']°t0� 3 _ Business Phone <br /> r �(����� Emergency Phone <br /> Contractor's Address _ No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r 1 <br /> WELL ABANDONMENT 13 OTHER PUMP INSTALLATION El PUMP PUMP REPAIR <br /> WELL CHLORINATION ❑ 'I <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines f l[�1�hME5 GLC�► �� <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/seepage Pit Other <br /> Sewage Disposal Field <br /> Public Domestic Well <br /> Property Line Private Domestic Well <br /> 11 <br /> INTENDED USE TYPE OF WELL �L <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation r <br /> ® DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑.DRIVEN <br /> 11 IRRIGATION ® GRAVEL PACK Depth of Grout Seal <br /> Type of Grout <br /> ® ROTARY <br /> ❑ CATHODIC PROTECTION Other Information � <br /> C1 DISPOSAL F-1OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL I <br /> PUMP INSTALLATION: Contractor 1 <br /> H.P. <br /> k Type of Pump <br /> E PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 11State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <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 /> of the work for which this Home owner or licensed agent's signature <br /> in such mannerfollowing: <br /> asto belcomecertify <br /> subject to workm n's compen ati n flaws of Cal forna." <br /> is issued, I shall not employ any person <br /> Contractor's hiring or sub-contracting signature certifies the following:1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ kpersons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: Dale: <br /> r Signed X t <br /> I (Draw Plot Plan on Reverse Side) <br /> l J FOR DEPARTMENT USE ONLY <br /> PHASE I Date 01 <br /> Application Accepted By <br /> Additional Comments: Phase It Final Inspection <br /> i Phase II Grout Inspection Date <br /> Inspection By <br /> Date Inspection By <br /> Fee Is Due' ❑ ANNUALLY [3 PER UNIT El PER S1TE - ❑ EACH ❑ January 1 E.Received By January 31 ❑ July 1 &ReceiveR�EBMyIT 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE iEXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 ` <br /> � FEEy_ <br /> I LESS <br /> i PRORATION <br /> PLUS Y <br /> _a L <br /> ENALTY <br /> y <br /> FTHER <br /> THER,— <br /> 7 N IRR-9 <br /> ` r Permit N S 5 Issuance Date Mailed_ Delivered <br /> Received l'y .^ Date Receipt No. - CA 95201 <br /> ( - ENVIRONMENTAL.EALT,PE.RMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 57OCKTON, <br /> APPLICANT—RETURN ALL COPIES 70: ` <br />