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l APPU"' arts MU be rrocessea rrnen juAmixteu rropuny t, r ,uw . c.e ure 1 U Jlyn �nn n�aaiie;at:u.�. <br /> �. FOR OFFICE: USE: '} APPLICATION <br /> / yyI)AA '(for Non-Transferable, Revocable,Suspendabl, <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 Joaquin Local Health District. <br /> 7 Exact Site Address N E,� -dy City/Town +�-��'� <br /> Owner's Name 10 e Phone <br /> Address v x City <br /> Contractor's Name _ S 7'-0"J 4P 9!54-K e . f4—4) License#/43.771- `� Business Phone ler 6 ;7 <br /> Contractor's Address - Glt. .f' m Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File dth SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ Q} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR t <br /> REPLACEMENT❑ <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 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i ❑ 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 /> i <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> l' ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor s l e. . <br /> Type of PumP H.P. <br /> PUMP REPLACEMENT: State Work Done .r lAt 10 rp�/ <br /> PUMP REPAIR: ❑ State Work Done <br /> F DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> FI 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 /> Homeowner 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 wIl call for a Grout Inspe 11 o So rou g and final inspection. <br /> F Signed X Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> F PHASE I c/ <br /> Application Accepted By �-1 .: Date <br /> Additional Comments: <br /> F. Phase II Grout Inspection / Mase III Final Ins ction ` <br />{ Inspection By' Date Inspection By ate '2 U <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 /> BASE EXPLANATION BILLING REMITTANCE § AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> F LESS <br /> PRORATION <br /> PLUS <br /> F, <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Fill <br /> G S <br /> Received by Date Receipt Na. Permit No. Iss ante Oate Mailed Delivered <br />