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uPrceenons vlrm tieProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application.r <br /> FOR O FICE;USE: :. � APPLICATION l �-�--- <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (%MPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconstruct <br /> and/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County d' ante No. 1862 and the rut and regulations of the San Joaquin Lo aIJ-ibed. his application <br /> )" Exact Site Address ' 011 <br /> r <br /> � �Cy/7own <br /> Owner's Name r �g <br /> Address Phone J <br /> City <br /> r Contractor's Name der�, License# 4ak <br /> Contractor's Address usiness Phone <br /> Emergency Phone „ <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes <br /> L-Ol No <br /> TYPE OF WORK (CHECK): NEW WELL900- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> REPLACEMENT❑ '� NIJMP REPAIR El <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesLJ� <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage PitOther <br /> _ <br /> Property Line Private Domestic Well <br /> ` INTENDED.USE Public Domestic Well <br /> TYPE OF WELL <br /> ❑,--,�INDUSTRIAL ElCABLE TOOL to <br /> PODOMESTIC/PRIVATE Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> El DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION Gauge of Casing _.,_ <br /> ❑ GRAVEL PACK Depth of Grout Seal" <br /> ❑ CATHODIC PROTECTION 5KROTARYW <br /> DISPOSAL <br /> ❑ Type of Grout � <br /> ❑ OTHER Other Information - <br /> ❑ GEOPHYSICAL 1' <br /> Surface Seal Installed By: r �-- <br /> PUMP INSTALLATION: Contractor 1111 1:11cillill. 11 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT; ❑ State Work Done <br /> PUMP REPAIR: rt ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done.inaccordance with Sari 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; <br /> permit is issued, I shall employ persons subject to workman's "I certify that in the performance of the work for which this r <br /> compensation laws of California. , <br /> w r a Grout Inspection p '. r to gro ing aV a final inspection. <br /> Signed X p <br /> Title: ___141lDate: <br /> (Draw Plo Ian on Reverse Side) <br /> PHASE <br /> OR DEP RTMENT USE ONLY <br /> 1 ! <br /> Application Accepted By <br /> Additional Comments: DateZ" <br /> Phase Gr t inspection y� P I Final I ction <br /> Inspection B �J Date l' ® Inspection By <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT t <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE Oma, x AMOUNT <br /> o-o <br /> LESS 183 , <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date - Permit NReceipt No. r <br /> P o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P_O.Box 2009 STOCI(TON,CA 95201 <br />