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Ap ionWfVB®ProckWAb When Submitted Properly Completed. Be Sure To Sign The Applicatfon.� <br />' FOR G'FFICE USE: �g APPLICATION + <br /> SAN ;�;r 3;i (�.4IGUTransferable, Revocable,Suspendable) <br /> HEALTH � ��&�I RONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i Application is hereby made to the San Joaquin Local Health District fora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance wLth San Joaquin Cou Ordinarre No.M2 and the rules and regulations of the San J quin Local Health District. <br /> Exact Site Address f 1z ct-�PA— City/Town <br /> Owner's Name Phone '1 <br /> Address City �Ql C— j <br /> Contractor's Name -PY License# 5 Business Phone_ <br /> Contractor's Address Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ _ 04 <br /> TYPE OF WORK (CHECK): NEW WEL�K DEEPEN ❑ RECONDITION❑ DESTRUCTION© <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C3 <br /> REPLACEMENT❑ `f <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 /> ❑ NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC C1DRIVEN Gauge of Casing P <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal J <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout ?a t –� <br /> © DISPOSAL OTHER Other Information P ; <br /> ❑ GEOPHYSICAL Surface Seat Installed By: w t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 37e-D ` <br /> Describe Material and Procedure d <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 for which this <br /> permit is issued, I shall employpersons subject to workman's compensation laws of California." <br /> will c for a Grout In cttmn prior to grouting and a final irispection....- .c- <br /> Signed X Title: - Date: ?✓ <br /> w Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY JI <br /> PHASE I <br /> Application Accepted By 1_� Ar e-a- 07 <br /> Date <br /> Additional Comments: <br /> Phirge <br /> 1 out Inspection Pha a III FI al Inspection y <br /> Inspection 8y '� Date $ " Inspection By CODate <br /> Fee Is Due:'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 2 <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �./ c'; <br /> LESS _ - <br /> PRORATEON <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received py Date Receipt No. Permit No, Issuance ate .Mailed' Delivered 4 <br /> ONMENTAL HEALTH PERMITISERVICES tent o uATci rnu <br />