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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION 'I <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <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 No. 1862 and the rules and regulations of the San�oaqujn�Local Health District. <br /> ,/ I <br /> Exact Site Address )r City/Town Sane= <br /> Owner's Nam Phone <br /> Address 3 6,L,,���—r City I ' <br /> Contractor's Name ��¢. C /�. ��� License##fG 1-3 73 Business Phone <br /> Contractor's Address O Emergency Phone. ' 1 <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0�} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Q <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 Sea) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0 e�zz <br /> Type of Pump�� H.P. <br /> ❑ State Work <br /> PUMP REPLACEMENT: Done <br /> r <br /> PUMP REPAIR: 'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ( # <br /> +F! <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 agent's signature certifies the following:p I certify that in the performance of thework 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 /> Grout- spection prix .ta_grouting_and-a-final-inspection..F <br /> Signed X-. _{�.�itle: . _ Date: ! �l I <br /> (Draw Plot Plan on Reversf Sidej <br /> J <br /> FOR DEPARTMENT USE ONLY I. <br /> 4 <br /> PHASE I ` <br /> Application Accepted By Date <br /> Additional Comments: <br /> I Phase 11 Grout Inspection Pha a III Final Ins action <br /> Inspection By Date Inspection By/ Date ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received'By January 31 ❑ July 1 &Received By July 31 I <br /> f REMIT <br /> 3' BILLING REMITTANCE <br /> BASE EXPLANATION t AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> r J <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER Ji <br /> OTHER <br /> n _ <br /> Received by Date Receipt No. Permit No. Issuan ecDate .Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.:HAZELTON AVE.,P.O.Box 2009 STOCK-CON,CA 95201 { <br />