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_MOFFICEUSE: <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR <br /> ' � APPLICATION <br /> f (For Non-Transferable, Revocable, Suspendable) PUMP&WELD <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit toconstruct and/o]r install the work herein described.This application is <br /> made in compliance withta.Noaquin County Ordinanc No. 1862 and the rules and regulations of the San'Joaquin Local Health District. <br /> Exact Site Address ff C�,�P���`�'T; <br /> T City/Town <br /> Owner's NamePhone <br /> Address 240:3 .2/}G . R <br /> City �4C <br /> Contractor's Name �� �G �CLicense? Business Phone . -� <br /> Contractor's Address <br /> ;^ Ernergency Phone / ~ fel <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLD' DEEPEN'[]-- RECONDITION❑ DESTRUCTIONS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ .PUMP INSTALLATION ❑ PUMP REPAIR❑ U <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 'A&A/a:r Sewer Lines /V T T Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line-J� 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 b <br /> c ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /O Chi r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑. State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: •Well Diameter f� Approximate Depth fG D f T <br /> Describe Material and Procedure l T '� <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance ofthe 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:"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." i <br /> I will Cal for a Grout i spection prior-to-grouting and a final insp ion. <br /> _ ` <br /> Title: Date: <br /> Signed X J . L '+ <br /> (Draw Plot Plan on Rever Side) <br /> s } <br /> PHASEI F R DEPARTMENT USE ONLY t <br /> f - , <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III Fina nspection <br /> Inspection By Date Inspection By ate l4 �� <br /> k ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> F <br /> BASE' EXPLANATION, BILLING - REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED } <br /> AMOUNT <br /> FEE tl r <br /> LESS P / <br /> PRORATION +- - <br /> PLUS { 3 <br /> PENALTY -- <br /> OTHER <br /> OTHER - <br /> r. <br /> Received by ate - Receipt No. Permit No. Issuance.Date Mailed , Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESHAZEL <br /> - <br /> 1601 E.HAZELTON.AVE.�P,O.Box 21W� CKTON,CA 95201 <br />