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c Applications Will Be Processed When Submitted Properly Completed. Be sure I o wgn ,ne.+NN+�a„�„• <br /> FOR OFFI usE: APPLICATION t <br /> (For Non-Transferabje,Revocable;Suspendable) PUMP&WELL <br /> u ENVIRONMENTAL HEALTH PERMIT <br /> 'WA���uALITYADO—Z� <br /> t2 G r L x-! ,n a� ' <br /> (COMPLETE IN TRIPLICATE S �,¢27 .�0 <br /> Application isherebymadetotheSanJoaquinLocalHealthDistrictforaper� Ito construct and/or install. ...theworkhereindescribed.Thisapplication <br /> made in compliance with San Joaquin County Ord�nance o. 1 62 and the pvles and r g jations of the San JQaqui Health District. <br /> �^h,o/' 07�.r��` __��' fi�i City/Town - <br /> it Exact Site Address_ <br /> G r, <br /> Phone- <br /> Owner <br /> hone-_ ' <br /> i Owner's Name it f~e <br /> ', ,w � t. .. ..... ... .:� • CGu1N_ity 1 <br /> r <br /> Address - �.� 'License if Z :' Business Phone` �P �•� ,7 F/. <br /> Contractor's Name <br /> Contractor's Address __� -• 'ErTibrgency.Ph ne <br /> No <br /> Is Certificate of Workman's Compensation Ins ranee on File With SJLHD? Yes 0— <br /> TYPE OF WORK (CHECK): • NEW WELL DEEPEN ❑ - REC NDIT{ON❑ �' DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> ❑ J. 7 'm_ Nd o. - <br /> REPLACEMENT <br /> —�- Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank -1 Other <br /> Sewage Disposal Field �--- Cesspool/Seepage Pit <br /> Property Line �'� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL p �j� �� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— l <br /> ` ] DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> El PROTECTION Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor + <br /> H.P. <br /> Type.of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State�Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure t <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 haws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed permit <br /> ed agent's signature certifies the following:"I certify that to the performance of the work for which this <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California.” <br /> Contractor s hiring oe�ub-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 /> t Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY <br /> PHASE I _- `/lid i ,Date "�p 1 <br /> Application Accepted By•, <br /> Additional Comments,a{ <br /> _ - tease 117'arout-Inspection" r Phase III inert Inspection . <br /> • Date Inspection By =-Date <br /> -'inspection By ,�/JJ' <br /> �j BHeceived By'January 31 " ❑ July S Received 0y July 3 <br /> Fee Is Dile. ❑ ANNUALLY{. fER UNIT' PER ITE EACH <br /> • January REMIT <br /> A `. BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION I DATE i DATE REMITTED AMOUNT <br /> y � O <br /> FEE d <br /> a <br /> LESS yy ... <br /> PRORATION 9. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />