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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> Y (For Non-Transferable,'Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT (/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 'r, t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance U0. 1 22 an t e rules and regulations of the San Joaquin Lpcal Health District. <br /> Exact Site Address F 6) I,z (5 S, � - City/Town gn <br /> Owner's Name r. O ��G,ltjA rL Z ► Phone go <br /> Address , '.r, ,.` '� . "- 'City R. .' <br /> 1 <br /> Contractor's Name "� ; License#�// Business Phone Q y 7 .���Z P i <br /> Contractor's Address c '}'' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1� No f h ' <br /> TYPE OF WORK (CHECK): NEW WELER _. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ v ' <br /> —4)WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ l" <br /> DISTANCE TO NEAREST: Septic Tank. —549 "f Sewer Lines_,�� 4 Pit Privy <br /> Sewage Disposal Field- Z& t Cesspool/S eepage Pit Other -� <br /> Property Line.//) { Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �t r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> A DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing � ff� SS f <br /> ❑ IRRIGATION r�GRAVEL PACK Depth of Grout Seal ! <br /> ❑ CATHODIC PROTECTION daL ROTARY Type of Grout sr.> 'r A( <br /> ❑ DISPOSAL ❑ OTHER Other Information R <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _err j/�✓! <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <br /> 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 /> 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 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 per hs subject to workman's compensation laws of California." <br /> 1 w• all for a Lit I pecti of to grouting and a final inspection. <br /> Signed ) Title: A Date: �� R <br /> / (Draw Plot Plan on Rev r e Side) <br /> r FOR DEPARTMENT USE ONLY <br /> PHASEI a <br /> Application Accepte y Date <br /> Additional Comme S r1 <br /> Ph se 11 Grout Inspection Phase III Final Inspection <br /> 1 � <br /> Inspection By Date -7—ZS�k —EL— - Inspection By 1P" �� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY Z .x -� <br /> OTHER <br /> OTHER <br /> Received by - Date — Receipt No. Permit-No 4ssuancelDate Mailed oelivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC N:ZW520 } t <br />