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mppncauum; wu1 0e rruceeseu when auunuueu 1-10peny 1.01nP1elcu. ow oure 1 U.19n 1"e APPucau00. <br /> FOP OFFICE USE: APPLICATION <br /> or Non-Transferable, Revocable,Suspendable) - PUMP..&�LNEL¢. I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -3;'. <br /> 1ppl ication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work I erein:described.Thisapplication is <br /> nade in compliance with Sa Joaquin Co+unty9 dinance Not. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 'txact Site Address � c c M f 4 �/ �(' City/Town I 1 r` ox-A4 <br /> �+ � d <br /> owner's Name — ��� >�'� �7 Phone <br /> ne 71 2. F.E!iJ 6. A)l City �se— ti <br /> lddress rx <br /> Contractor's Name: �!'�c�`r-51rY/ License# PiG Business Phone ?� -2247 <br /> Contractor's Address Emergency'Ph'o/npe 'D <br /> s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> —rYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] /V\11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR -� <br /> aEPLACEMENTP <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy LP <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 11CABLE TOOL Dia. of Well Excavation <br /> yet�t DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> .0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> _❑ GEOPHYSICAL Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �^ <br /> PUMP REPLACEMENT: ;Q State Work Done ' ^i " ` U,e C� a <br /> —PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure � <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County �I <br /> ordinances.state laws, and rules and regulations of the San Joaquin Local Health District. CTi <br /> Homeowner or licensed agent's signature certifies thefollowing:"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 subcontracting signature certifies the following:"I certify that in the performance of the work far which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> _ I witj� II for <br /> �y�ro: t fi(teed prior to grouting and a final inspeccJl}' 'c^- <br /> Signed X �° Title: T � Date: <br /> JJJ/ (Draw Plot Plan on Reverse Side) <br /> r FOR DEPARTMENT <br /> USE <br /> , ONLY <br /> PHASE 1 .� Date <br /> Application Accepted By�11=__"" <br /> �. Additional Comments:_((( /// <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Date <br /> Inspection By M p y� �-/--< - Date <br /> Inspection B � --�— <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT CI PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July 1 8 Receive0 July 31 <br /> REMMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> L FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> Im PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> T— M nl A <br />