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�. Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> ,l OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) i l <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance W/h San 29a$77-PLL <br /> County Ordinance No 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 2 +Z � City/Town <br /> Owner's Name Phone <br /> Address /0-"- szy <br /> Contractor's Name License#3�;f�� Business Phone <br /> Contractor's Address A0 —Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WithLHR? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,NN�rr❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT IJ OTHER ❑ PUMP INSTALLATION K� PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy C1\I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> r❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excava ion <br /> 10.DOMESTIC/PRIVATE ❑ DRILLER Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Groouut,Seal..- J-+` &s , <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL s Surface_Seal Installed By: <br /> PUMP INSTALLATION: Contracto � � � / <br /> Type of Pump <br /> ,xr H.P. - <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth T <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this appiication'and thaVthe 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:"I certify that in the performance of the work forwhich 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 /> Contracto'r's hiring or sub-contracting signature certifies the fo.1lowing:"I'ceftify 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 wd1Lza9Lfqr a Grout Inspection prior to grouting and a final inspection. <br /> r <br /> Sign �� Title: &Er a -- Date: '719r_____._ <br /> } ! (Draw Plot Plan on Reverse Side) <br /> � I FO DEPART ENT USE ONLY <br /> PHA SEI <br /> Application Accepted By Date <br /> 11/179 ' <br /> Additional Comment§: <br /> Phase II Grout Inspection -Phase.III Final Inspection {, <br /> Inspection By Date Inspection By ate J tr <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 /> J BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 4 <br /> FEE YZ <br /> LESS <br /> PRORATION Y <br /> PLUS <br /> 'PENALTY <br /> OTHER <br /> OTHER _ �?- - <br /> VW <br /> 3135 <br /> Received by Date Receipt'No—, _ Permit No. Issuance�Date-� 'Wiled Delivefed <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTWPERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOf4,CA 95201 <br />