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ApplicationsWill BeProcessedWhenSubmitted Properly completes. taeSureTo51gn TneAppllcallon. <br /> FOR t'1FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WEL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE tN TRIPLICATE) WATER QUALITY F' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with SrJo uin Coun rd)nance No. 1 62 a d the rules d regulations of the San Joaqul Local Health District. —: <br /> Exact Site Address ,� City/Town p�c <br /> Owner's Name Phone l' <br /> Address n OIL Cityif <br /> Contractor's Name 'IAA Li nse#iC,2Pig fir` Busin ss hone <br /> Contractor's Address u Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ W <br /> TYPE OF WORK (CHECK): NEW WELL @§� DEEPEN ` RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 19-- OTHER ❑ PUMP INSTALLATION ig�' PUMP REPAIR❑ <br /> REPLACEMENT❑ M <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE J1(PE OF WELL fr <br /> ❑ INDUSTRIAL 9 CABLE TOOL Dia. of Well Excavation <br /> 9�<OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout G <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appr x'mate Depth <br /> Describe Materigyapd Pre �e 7 AlC� a C <br /> n �� -a <br /> I hereby certify that i have prep red this application and that the work ill 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:"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 for which this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspectiopri to grouting and a final inspection. j <br /> Signed I! Title: l f/WA, * Date <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ln. <br /> Application Accepted By `•' Date g <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN1T ❑ 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 /> \ w <br /> FEE 11 0 t 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5 � <br /> 71 "A 19-7- - �(� ?4 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK f a,C/, 5) L^ <br />