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. - <br /> Applications Will Be Processed When Submitted rope <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> [ ENVIRONMENTAL HEALTH PERMIT <br /> J-,c�-t/M4TER'QUALITY e&-' 67�-� 1 . <br /> (COMPLETE IN TRIPLICATE) O �' S r <br /> i Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.Thisappllcationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and.the ruI sand regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address /Q- <br /> Phone <br />( Owner's Name <br /> 1 Address License# Business Phone +CI <br /> re.« <br /> Contractor's Name mergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance.on File With 5JL D? Yes` � <br /> TYPE OF WORK CHECK): NEW WELL C] DEEPEN ❑ ` RECONDITIONS utSTRUCTION❑ AIR❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLAT101V PUMP REP <br /> REPLACEMENT❑ <br /> ' Sewer Lines - Pit Privy `11 <br /> DISTANCE TO NEAREST: ,Septic Tank Cesspool/Seepage Pit Other <br /> j <br /> -Sewage Disposal Field ` <br /> lF Property Line Private Domestic Well Public Domestic Well <br /> i INTENDED USE s _ TYPE OF WELL <br /> ❑ INDUSTRIAL a s ❑ CABLE TOOL Ria. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE } ❑ DRILLED Dia. of Well Casing y ! <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gaugeof Casing a <br /> IF IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION <br /> 13 ROTARY Type of Grout <br /> s 11 OTHER Other Information <br /> El DISPOSALBy- <br /> El <br /> I <br /> ❑ GEOPHYSICAL Surface Seal installed By: � <br /> PUMP INSTALLATION: f <br /> Contractor.- <br /> ontractor a0r <br /> i, Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> El State Work Done <br /> ' State <br /> PUMP REPAIR: Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure f� <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> � I <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 certifyFthat in the performance of the work for which this permit C <br /> 1 *'is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." � <br /> ollowing:"I certify that in the performance of the <br /> Contractor's hiring or sub-contracting signature certifies the fwork for which this } <br /> ject to workman's compensation laws of California." <br /> permit is issued, I shall employ persons sub <br /> I wily call for a Grout Inspect! n io t grout and a final inspection. <br /> 1P Date: <br /> 1tle: <br /> Signed X ` t (praw Plot an on Reverse Side) <br /> I . <br /> FORD PARTMENT USE ONLY <br /> F PHASE 1 � a Date ! <br /> Application Accepted By <br /> Additional Comments: <br /> h I lnal Inspection Z <br /> _ Phase II;Grout Inspection Date <br /> Date Inspection B <br /> I Inspection By `�< r <br /> ❑ Januar 1 &Received ey January 31 ❑ July 1 &R ved Bu'July 31 '� <br /> Fee Is Due: ❑ ANNUALLY 11 PFR UNIT, ❑ PER SITE ❑ EACH y REMIT.< <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION'-, DA DATE REMITTED AivID4^INT <br /> FEE P rt <br /> r <br /> LESS <br /> PRORATION 4 <br /> L PLUS v <br /> PENALTY <br /> • <br /> OTHER ' - R <br /> OTHER ` <br /> m issuance t are Delivered " <br /> Permitmil N I e D8 e Mai d <br /> , — Received by} �`+ .'+ DaterT. Receipt Ngo wtiar _, - - <br /> + COPIES TO: ENVIRONMENTAL HEAkxN EAMITISERYICES _ 1601 S.HAZELTON AVE,P.O.Box 2009 STOCKT ,CA 95201- <br /> .. - — <br />