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Applications Will Be Processed When Submipea rropeny %,umNrctoa+• <br /> APPLICATION /} <br /> FOR,I�fFICE USE: t.;�„,� )i <br /> 4 (For Non-Transferable, Revocable, Suspendable) PUMA'&WELL <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> t WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with-San.,ioaa�� ty O� r��ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Owner's Name. O `r E A AX Phone <br /> City <br /> k Address <br /> Contractor's Name" S �-� �'L &,ftense# q1� Business Phone ? d 9 Q�T <br /> Contractor's Address <br /> F3S E j c K Emergency Phone — 0� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_� No oa <br /> EL <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13RECONDITION 1:1 DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: M State Work Done <br /> DESTRUCTION OF WELL: Well Diameter L � Approximate Depth <br /> _T_e eu <br /> Describe Material and Procedure I- *. <br /> S =4ZC [.0 'LO c <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County G , <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 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 /> r Contractor's hiring or sub-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 /> 1 wi call for a Grout In pection prior to grouting and a final inspec n. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> \1\1. Date y <br /> k PHASE I vt7'aM <br /> Application Accepted By <br /> i Additional Comments: <br /> Phase 11 Grout Inspection Phas I Final Inspection <br /> Inspection By Date <br /> Inspection By Dat <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July i &Receiv RJuly 31 <br /> EMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t i}� DATE DATE REMITTED AMOUNT <br /> FEE `LJ G <br /> LESS <br /> PRORATION <br /> A <br /> PLUS <br /> PENALTY ¢h <br /> OTHER - <br /> OTHER -976 <br /> 'Q7]( 16577. <br /> *��.. Received by <br /> Date Receipt No. Permit 1,40. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOGKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _rt <br />