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r ApplicationsWill Be Processed When SubmittedProperly Completed. Be Sure To Sign The Application. -_— <br /> DFORFI e usE: APPLICATION <br /> (For Non-Transferable, , pe) <br /> w�wRevocableSusendabl <br /> � <br /> t ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN'TRIPLICATE) WATER QUALITY <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 <br /> made in compliance with San Joaquin County Ordinanco. 1862 and the rules and <br /> TY <br /> Owner's Name regulations of the San Joaquin Local Health District. <br /> Exact Site Address ,�©cs ,� � RNA L ii=_ City/Town <br /> i <br /> Address ` <br /> Phone <br /> city <br /> Contractor's Name tr FNA11A14=S-- License# Q / / �-5- <br /> 3S. S Business Phone <br /> Contractor's Address p A-,ta aY�t� M0, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELIA <br /> DEEPEN ❑ RECONDITION E] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank l 0 + Sewer Lines <br /> r Pit Privy <br /> Sewage Disposal Field. f Cesspool/Seepage Pit other flC1 <br /> C Property Line Private DomesticWell Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE❑ <br /> TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Casing <br /> ❑ IRRIGATION IIS�T <br /> 1�GRAVEL PACK Depth of Grout Seal SG <br /> ❑ CATHODIC PROTECTION 9 ROTARY Type of GroutiCera.rrrrrT <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL t <br />' { Surface Seal Installed By: (� t b <br />' PUMP INSTALLATION: IF <br /> ,Contractor fA <br /> I <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work bone <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth i <br /> De trib�ial ep{ure <br /> I hereby certify that I have prepared tthat the wo will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I wil!call a Grout I pectio prior to grouting d a final inspection. <br /> Signed X Title: <br /> bate: icy � <br /> (Draw PI Ian on Reverse Side) <br /> M <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ^ <br /> Application Accepted By Com';`Aa.0._ <br /> Additional Comments: Date <br /> Inspection By <br /> P ut nspection/ r � Ph a a III F' al Inspection <br /> Date (� Inspection By Date <br /> Fee Is Due:,IJ ANNUALLY ❑ PER UNIT ❑ PER SITEr <br /> ❑ EACH ❑ January 7 &Received By January 31 ❑ July 7 &Received By July 31 <br /> BILLING REMITTANCE REMIT ) <br /> BASE EXPLANATION - $ A ' <br /> ` DATE DATE REMITTED MOUNT DUE CHECKED <br /> FEE � ,j �a� AMOUNT <br /> LESS X!/ <br /> PRORATION .E <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Recei d ate Receipt N - Permit No. - <br /> Issuanc Date Maiied Delivered <br /> APPLI NT—RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMIT/SERVICES '.' <br /> - _ 1601 E.HAZELTUN AVE,,P.O.Bax 2009 $TOCNTON,CA 95201 <br />