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Applications Will Be Processed When Submitted Properly Completed BeSureTosign meAppneunvn. <br />+� FOR OFFICE USE: APPLICATION t <br /> (For Non-Transferable, Revocable, Suspendabie) <br /> ' PLUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> S <br /> (COMPLETE IN TRIPLICATE) �� S• �£e¢+.�S1r.���Wj-ATER QUALITY e(f�BalthDistrictforapermittoconstructand/orinstalltheworkherein described.This application is <br /> Application is hereby made to the San Joaquin Local HiDalth t <br /> made in compliance with SariJoaquin County Ordinance No. 1862 and the r les a d regu�tio�s a,�th�5an Joaq in Local Health Istric <br /> Exact Site Address <br /> y _ V14�C� �. fit/ Go y�'o J�i lM- w.' CCS�r 4=�' <br /> S' - 022 L ' <br /> Owner's Name P - Phone <br /> Address <br /> Contractor's Name r� [ License# Business Phone <br /> c�-- <br /> Contractor's Address nP K[(J^aT Emergency Phone -` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLK DEEPEN El RECONDITI ON <br /> L� DESTRUCTION❑ E]WELL CHLORINATION E] WELL ABANDONMENT 13 OTHER E] PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> DISTANCE <br /> Disposal Filld Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well "5—' Public Domestic We 11 <br /> INTENDED USE TYPE OF WELL r I <br /> k ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> )(DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C3 DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK v Depth of Grout Seal 0 ' <br /> k ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> C1DiSPOSAL C1 OTHER Other Information - <br /> 11 GEOPHYSICAL <br /> { Surface Seal Installed By: /y! +tp <br /> ! PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done_ - <br /> 1 PUMP REPAIR; 10 State Work Done - i- . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> # Describe Material and Procedure <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 /> 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, l 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, I shall employ persons subject to workman's compensation laws of California." <br /> I will or a Grout Inspection prior to grouting and a final inspection. <br /> Title: _ _ _ Date: <br /> Signed X <br /> 1 raw Plot Plan on Reverse Side) <br /> r.. <br /> FOR D ARTMENT SE ONLY <br /> PHASE I y ?� <br /> • Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Dake Inspection By C r ate 7' LO <br /> Inspection�y •'7`1� - <br /> 31 <br /> Fee Is Due: ❑ ANNUALLY WI 10 ' �� PER UNIT ❑ PER S ❑ EAG ❑ anuary 1 &Ree y January 31 El 1 &Received By July- <br /> 4 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> _ 4�3 ✓ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> c <br /> Ci <br /> OTHER <br /> '' Received by` Date t Receipt No. Permit No. Issuance Date. Mailed Oelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.-BwC20�OCKTON,CA 85201 <br />