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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application.� 1 <br /> .FOR OFFICE USE: APPLICATION <br /> i (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMITr <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 4471 <br /> Application is hereby madr. <br /> e 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 Ordinance No. 1862 and the;rules and regulations Di'the San Joaquin Local Health District. <br /> Exact Site Address . City/Town - <br /> Owner's.Narlie Phone�' - � '— <br /> Address GCity/';,, o ;- �_r• ` <br /> . —�J <br /> Contractor's Name License Business Phone ' <br /> Contractor's Address ;n 1 <br /> Emergency Phone" <br /> Is Certificate of Workman's ompensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): - NEW WELL❑ DEEPEN ❑"�' `RECONDITION❑ - 'DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION EL--- PUMP REPAIR El J <br /> REPLACEMENT❑ it <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL fi <br /> ❑ INSI1STRlAL �. ❑. CABLE TOOL _ Dia, of Well Excavation <br /> DOMESTIC/PRIVATE I; ❑ ^� <br /> DRILLED Dia. of Well Casing <br /> 1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i, ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 0 DISPOSAL I <br /> ❑ OTHER Other Information ` <br /> GEOPHYSICAL Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor <br /> M Type of Pump H.P. <br /> PUMP REPLACEMENT. u, ❑ State Work Done <br /> PUMP REPAIR: ;o i❑ State Work Done <br /> DESTRUCTION OF WELL: ' Well Diameter <br /> i Approximate Depth <br /> i 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 /> Home owner or licensed a <br /> gen 1'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 an person in such <br /> Y P manner as to become subject ct to workman's compensation laws of California.". <br /> Contractor's hiring orsub-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." <br /> I will r a Grout knspection prior to grouting and a final Inspection. <br /> Signe Title: <br /> R Date: _6? <br /> (Draw Plot Plan on Reverse Side) <br /> f' FOR DEPARTMENT USE ONLY <br /> PHASE I �? <br /> Application Accepted By 4,/ <br /> Additional Comments: r <br /> bate <br /> Phase II Grout Inspection P Pha I all Inspection <br /> Inspection By t Date.- By 8y <br /> Fee Is Due: © ANNUALLY' ❑'PER UNIT; ❑ PER SITE ❑ EACH ❑ January't-&Received By January ❑-July I &Received By July 31 <br /> ' BASE 1!''' - EXPLANATION - ,BILLING REMITTANCE - REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS r �� <br /> PRORATION - <br /> - a I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I I <br /> OTHER '' <br /> Received-by _ _.Date i� Receipt No— ... .Permit No., - <br /> _ I suance 1e Mailed Delivered: <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.',P.D.Box 2004 <br /> III - .-. - Delivered, <br /> CA 95201 <br />