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" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: //-- APPLICATION <br /> r Co lite,�b4' (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT / PUMP&WELL <br /> �E WATER QUALITY <br /> (COMPLETE IN TRIPLICATE l_.�,•,� - :3�� � <br /> Application is hereby made to the San Joaquin Local Health Dl'96W for a permit to construct and/or install the work herein described.This application is <br /> mad;in compliance with SenJoaquin Coun�tay�Ordi ance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address RAW S'�bTw a //y <br /> •r r ---���e. .art Ca/er✓si�P re✓ City/Town a Os� a N{$n/m/ <br /> Owner's Name _ _ ud— Phone - <br /> Address S — -cyPOLI <br /> ContraCtor's NameCity_ <br /> License a /fJ-7 M Business Phone Y —Zli 7 <br /> Contractor's Addres Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on F e With SJLHD9 Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT I] OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR,W <br /> REPLACEMENT❑ <br /> r DISTANCE TO NEAREST: Septic Tank Sewer Lines . Pit Privy <br /> u` 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 Die. of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 54 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL .J Surface Seal Installed By: <br /> PUMP INSTALLATION: - _I Contractor <br /> �i Type of Pump—�-tr:�� 5'r H.P. SLA <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 1 PUMP REPAIR: State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> i Describe Material and Procedure <br /> ( <br /> I <br /> 11 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County '.,. <br /> i0 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 /> a 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 certifiesthe following:"I certify that in the performance of thework forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ��{'II��wy I call for a Grouttinsp io prio o I tin4anfinal inspection. <br /> Signed XC�r♦titl G�lr,t.. �d itle: P/•� Date:(Drawn on Reverse Side) <br /> N .. FOR DEPARTMENT USE ONLY <br /> PHASE I - \^ <br /> • Application Accepted By \ Date <br /> ' Additional Comments: • _ <br /> ti <br /> EEE � Phase II Grout Inspection Phase 111 Final Inspection y <br /> Inspection By Date Inspection Bye'✓(, OXO— Date 6 �� <br /> ri <br /> IIV Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 E Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DAT flEMITTED AMOUNT DUE CHECKED <br /> p AMOUNT <br /> FEE <br /> 1' <br /> d LESS <br /> d PRORATION <br /> I PLUS <br /> . PENALTY ' <br /> I _ <br /> b OTHER <br /> d OTHER <br /> l�L� ,7—1 <br /> ,� Racelved by Date. R.Ipt No. Permit No. Issuance Data Melted Dellvered <br />