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ApplicationsWillBeProcessedWhen submilteaPropenyGomplew. tiesure iosign IneApplication. <br /> vUn OF ICE USE: APPLICATION <br /> (for Non-Transferabte,Revocable, Suspendall <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY C <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 t <br /> made in compliance with San a in COu ty Ordinance No. 1862 and the rules and regulations of the San Joa�c uin Local Health District. <br /> Exact Site Address___.._� 'tet CitylTown <br /> + Owner's Name _v h Phone / <br /> Address - City_ <br /> -..���i.• ivy r,. Z <br /> Contractor's Name __.6� �,,� �em,t z, ,�license ft y1 / Business Phoneme <br /> Fi Contractor's Address __� __ F.y-'- Emergency Phone 1 =( �7�- _Is Certificate of Workman's Compensation_Insurance on File With SJLHD? Yes No _,..-. <br /> TYPE OF WORK (CHECK): NEIN WELL DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 1:1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /l i"/ Sewer Lines Pit Privy <br /> Sewage Disposal Field [:�.....� Cesspool/Seepage Pit Other <br /> .Property Line_�2�5__ Private Domestic Well__77/ Public Domestic Well <br /> INTENDED USE TYPE OF.WELL <br /> ❑ INDUSTRIAL ❑,t CABLE TOOL Dia. of Well Excavation'- <br /> 13 DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> JZ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing �xs�/h'J /&A - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat V <br /> F <br /> El CATHODIC PROTECTION ❑ ROTARY Type of Grout ._ z_r`. <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> F! <br /> PUMP INSTALLATION: Contractor .^ <br /> + <br /> Type of Pump r`. H.F. _f 1fF <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> k PUMP REPAIR: ElState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> F.: 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 taws 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 /> F. permit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> I wilt call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � Title: c=7 �`�^ Date: l <br /> Ft' <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I � <br /> Application Accepted By �`�` a / Date Q U <br /> Additional Comments: <br /> Pbase It Grout Inspection P I incl Inspection <br /> Inspection By Date 3f J3}Sa Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> 611-LING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DOE CHECKED <br /> .AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> - <br /> PLUS — - <br /> PENALTY <br /> OTHER <br /> OTHEH - <br /> Qq-1,3 p <br /> Received by Date Receipt No. Permit No.' I suance Daie - Mailed DefI <br /> APPLICANT-RETURN ALI.COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HATELTON AVE..P.O.Box 2009 $T C ./CA 95201 —� <br />