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Applications Will Be Processed When Submitted Properly Completed. Be Sur To Sign The Application. . <br /> FOR OFFICE USE: APPLICATION <br /> 'CGIFor Non-Transferable, Revocable, Sus endable( P ) /] PUMP&WELL <br /> ~� ENVIRONMENTAL HEALTH PERMIT / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY l <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 f <br /> made in compliance with San Joaquin County Ordinance�4o62 and the rules and regulations of the San Jopuin_�LLocal Health District. <br /> Exact Site Address :*7.3 0 ilk � City/Town - QZ V%6•y-- <br /> S. <br /> Owner's Name _ i 1v sd s Phone <br /> Address M.Un City- <br /> Contractor's <br /> ity Contractor's Name License# Business Phone ` -7 6-? to <br /> Contractor's Address , Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- V No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION u DESTRUCTION❑ C� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION. ❑ ROTARY Type of GroutIX <br /> ❑ DISPOSAL ❑ OTHER Other Information C ' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ✓ <br /> PUMP INSTALLATION: Contractor W V- <br /> Type of Pump ' f H.P._ �^ <br /> PUMP REPLACEMENT: ❑,,State Work Done <br /> PUMP fi0WR: ® State Work Done e► Lf -T/ U <br /> DESTRUCTION OF WELL: Well Diameter X pproximate 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 /> 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:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE y <br /> Application Accepted CH Date <br /> Additional Comments: <br /> Phase II Grout Inspection -Phase III Final Inspection <br /> Inspection By Dale inspection By=:,,- <br /> �f 6te lam✓ 7'- G <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 R119TANCE $ AMOUNT DUE CHECKED <br /> DATE ATF REMITTED AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I' <br /> OTHER <br /> t <br /> Received by Date Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO- FNVIRnNYFNTAI Neel Tu o6:ou6T1ecoV4r•ee tem a .A- rn.,A... rA—.1 <br />