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' Applications Will Be Processed When Submitted Properlycompietea. neaura 111 olu GFOR O <br /> FFICE APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> i <br /> ENVIRONMENTAL HEALTH PERMITWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he <br /> described.This application is <br /> an Jo uin Co my Or i ance No. 1862 and the r e and regulations <br /> of the San J aquiin Local Health District. <br /> made in compliance with S <br /> Exact Site Address f r <br /> Phone <br /> Owner's Name City <br /> Address ( (y License# Business Phone `f✓ ��� <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No �asr <br /> ? Yes <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD <br /> TYPE OF WORK (CHECK): NEW WELL IiJ� uEEQEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT Sewer Lines !� Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank `mss <br /> Sewage Disposal FieldCesspool/Seepage Pit � �.: Other �- <br /> /[t� <br /> lit, <br /> Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED'USE ��,, �TYPE OF WELL <br /> 0-GABLE TOOL Dia. of Well Excavation ee <br /> El IND STRIAL <br /> f ❑ DRILLED Dia. of Well Casing <br /> M-150MESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION <br /> ❑ CATHODIC PROTECTION C1 ROTARY of Grout ROTARY \ <br /> j ❑ OTHER Other Information A <br /> ❑ DISPOSAL J t <br /> 11 GEOPHYSICAL - - Sur ace Seal Installed By: � <br /> I Contractor rl <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i. PUMP REPAIR: ❑ State Work Done <br /> ' Well Diameter Appy ximate DepthNoaqwn <br /> � <br /> DESTRUCTION OF WELL: - 'r Des ribe Material and Proc Jure �, rheI hereby certify that I have prepared his a lication and that work will be done in accordance with SaCounty <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 /> r° permit is issued, 1 shall employ persons subject to workman's compensation laws of California. <br /> 1 ill II for a Grout ins Clio prior to grouting and a final inspection. <br /> r.. Title: C --& Dale: tf <br /> Signed X m (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 0 �/ 7/ 8Date <br /> 1 Application Accepted By I b r,t ; V <br /> Additional Comments: o p se IN Final 1 e tion <br /> e ll Grout Inspec' neA to <br /> Inspection By <br /> Date Inspection By <br /> s <br /> ` ❑ January 1 &Received By January 31 ❑ July 1 &Received ay July 31 <br /> 7. Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER.SITE Li REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE C7 0 <br /> P LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received byAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,AYE.,P.O.P.o.Il STOGKTON,-CA 95201 <br />