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pplicatiorf si y11a11 9e Processed Wheni&�.i#L{ Properly Completed Be Sure To Sign The Application <br /> AII <br /> FQR OFFICE USE: QQpp LICATION <br /> 1(For 499iransferable, Revocable,Suspendable) <br /> n PUMP&WELL <br /> SAN JC),m og lyl �I� ENTAL HEALTH PERMIT ' <br /> (COMPLETE IN TRIPLICATE) HEALTH'DISTRICT, 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 /> r <br /> made in compliance with San Joaqu n County Ordinance No. 1862 an rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address ' <br /> City/Town <br /> Owner's Name _ <br /> Address f Phone <br /> Contractor's Name City <br /> Contractor's Address ' Li ense# Bu iness'Pho e <br /> Is Certificate of Workman's Compensation Insurance onFileWith SJLHD? erg YesencPhone _ <br /> . TYPE OF WORK (CHECI(): NEW WELL❑ Yes Na <br /> WELL CHLORINAT N ❑ -DEEPEN ❑ -RECONDITION❑ DESTRUCTION❑ " O6 <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> i Sewer Lines Pit Privy <br /> Sewage Disposal Field Pity , <br /> Property Line Cesspool/Seepage Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ INDUSTRIALTYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTfC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC Dia. of Well Casing <br /> ❑ IRRIGATION Y� a ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY 3 <br /> ❑ DISPOSALType of Grout <br /> GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: T <br /> Type of Pump �.,. <br /> PUMP REPLACEMENT: nr���SiatH.P �— <br /> - +� e Work Done _ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Cr� <br /> TI <br /> z Describe Material and Procedure Approximate Depth <br /> I hereby certify that I.have prepared this applicatior 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. r <br /> Home owner 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 forwhich this <br /> permit is issued, I shall employ-persons subject to workman's compensation laws of California." <br /> I will call for a Gro Inspection prior to tin and final in tion. <br /> Signed X <br /> lot Pla Date: <br /> Draw P <br /> everse Side) <br /> FOR DEPARTMENT USE ONLY'-— <br /> PHASE I i <br /> Application Accepted By <br /> Comments: Date <br /> [Additional <br /> Phase I! Grout Inspection ' <br /> Inspection $y eFinal Inspection 2 <br /> Date Inspection <br /> � � bate <br /> Fee Is Due: 11 ANNUALLY .4"❑ PER UNIT! ❑ PER SITE <br /> ❑ EACH ❑ January'1 eceived By January 31 <br /> ❑ July 1 &Received By July 31 <br /> BASE BILLING. ;. <br /> � EXPLANATION- REMITTANCE a $ REMIT � <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS ^ $ Q <br /> PRORATION .. <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> If 'I <br /> 1 s <br /> Received by ,..•. - Date. <br /> Receipt No. Permit No. l <br /> APPLICANT—RETURN ALL OOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issua ce O to Marled "Delivered <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 crn1i <br />