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Applications Will Be Processed-When-Submitted-P_roperly_Completed. e u i <br /> F�1R OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) SUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 compliance with San Joaquin County Ordinan e No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address _ <br /> Phone res ' <br /> Owner's Name <br /> City <br /> Addressj $'I r- <br /> Contractor's Name License#.�-i�`'E �� Business Phone <br /> Contractor's Address aF Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> ��� No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ I TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ipOMESTIC/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 <br /> i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �; <br /> Type of Pump - H.P. W <br /> PUMP REPLACEMENT: { ❑ State Work Do a �? <br /> 10 State Work Done <br /> i PUMP REPAIR: f zsr i ; <br /> DESTRUCTION OF WELL: � <br /> / Well Diameter Approximate Depth <br /> f } <br /> Describe Material and Procedure'' " <br /> r1 _ <br /> I hereby certify that have prepared this application and that-thework will be done in accordance with.Sari 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 became subject <br /> to:' 's compensation laws of California." C <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> �t -<—permit—is issued,il shall employ persons subject to workman's compensation laws of California." <br /> 1 will ca or a Griaut spection prior to grouting and a final inspection. <br /> r ! � � <br /> -- Title: I Date: <br /> I Signed <br /> i (Draw Plot Plan on Reverse Side) ...- <br /> I r FOR DEEARTMENT USE ONLY <br /> PHASE I - Dat7_�J�/ /90 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Gr ut Inspection Ph se 11 1,Inspection l <br /> Date Inspection B Date �>IZ)1 c <br /> • inspection 8y . <br /> By J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 I] July 1 &Receive EMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> !' LESS <br /> PRORATION <br /> PLUS <br /> ! PENALTY <br /> OTHER <br /> OTHER <br /> S 5P <br /> Received by <br /> Date x Receipt No. Permit No. Ie Date Mailed Polivered. <br /> 1601 E.HAZELTON AVE.,P.O.box 2009 S70C1(TON <br /> APPLICANT—RETURN ALL COPIES TO:--ENVIRONMENTAL HEALTH PERMIT/SERVICES ,CA 952WOW <br />