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y �4� Applications Will Be Processed When Submitted Properly Completed. Be SureTosignTneApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <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 ce th San Joaquin County Ordinance No. 1852 and the <br /> irules <br /> and regulat' of the San J quin <br /> te A Local Health District. <br /> Exact Sidressy ��� r`f [""- gown <br /> Owner's Name O Phone?'/-7--3 i <br /> Address — <br /> e '� City cn jfw. <br /> Contractor's Name /i/ �` cense#�� Business Phone_ Q"�/7--d <br /> Contractor's Address .Emergency Phone R <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yesy No <br /> TYPE OF WORK(CHECK): NEW WELL Cf-'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT 11OTHER El PUMP INSTALLATION 2�- PUMP REPAIR❑ <br /> REPLACEMENT❑ ! <br /> DISTANCE TO NEAREST: Septic Tank ,P�Q `7� Sewer Lines Pit Privy !� <br /> Sewage Disposal Field ~D 'f 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 S <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ROTARY Type of Grout <br /> E C a AIC <br /> 1:1 DISPOSAL ❑ OTHER Other Information a <br /> ❑ GEOPHYSICAL Surface Seal Installed By fwAt <br /> PUMP INSTALLATION: Contractor- <br /> SH.P. <br /> Type of Pump Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f 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 <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." t+� <br /> 'll call for a Grout I ri 1 routing and a final inspection. <br /> ' Date: <br /> Si Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date <br /> Application Accepted <br /> Additional Comments: <br /> rout Inspection �j�l7b(��r,� a II ilial Inspections <br /> Inspection y Date W- (_. Inspection B Date <br /> Fee is Due: ❑ NNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & eceived By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> +I DATE DATE REMITTED AMOUNT <br /> f FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r Received by D e Receipt Nd. h Permit No. -- Issuance Date_A ,-Mailed_—_;.,Deli_vered'F <br /> Y <br /> '+ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTlSERVIGES _?6_0f E:HAZELTON AVE.,P.O�11;°_Ocl-ro GA 95201 <br />