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_ p z , <br /> ...L� Applications Will Be Processed When SubAmPPL�CATION <br /> OR OFFICE USE: <br /> f <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL i <br /> .k ENVIRONMENTAL HEALTH PERMIT <br /> s .J` 'WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ', '�D 1. S'• 0 <br /> Application is hereby made to the SanJoaquinLocalHealthDistrictforapermittoconstructand/orinstallthework herein described.This application is <br /> ` made in compliance with San Joa in County Ordinance No. 18 2 an t e rules and regulations of the San Joaquin Local Health District. <br /> C ity/Towp <br /> ` Exact Site Address de/ a /r,yfk�d fa /',l,r•��pAA�3��o ��-,q <br /> Owner's Name `d l City <br /> ne <br /> Address I <br /> Contractor's Name <br /> E � License Business Phone <br /> I Emergency Phone <br /> Contractor's Address <br /> y� <br /> � Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13RECONDITION 13 DESTRUCTION PUMP REPAIR❑ O <br /> 1 WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER <br /> ❑ PUMP INSTALLATION <br /> REPLACEMENT❑ �.� 'fI <br /> DISTANCE TO NEAREST: Septic Tank <br /> 5e r';.Lines Pit P,r`ivy � <br /> Sewage Disposal Field 1 C$spool/Seepage Pit 3' � 1 Other <br /> Property Line Private Domestic Well Public Domestic-Well <br /> INTENDED USE TYPE OF WELL s <br /> of Well Excavation <br /> ❑ ❑ <br /> INDUSTRIAL CABLE Ob Dia. <br /> " <br /> DOMESTIC/PRIVRTE <br /> El DRILLED 4 Dia. of Well Casing <br /> ❑ RIVEN Gauge of Casing <br /> C] D <br /> DOMESTIC/PUBLIC Depth of Grout Seal�(MJ&-;1❑ IRRIGATION ❑ GRAVEL PACK �— <br /> } ❑ ROTARY Type of Grout <br /> 13CATHODIC PROTECTION. f, [ - Y <br /> j. ❑_D,ISP.O_SAL * O-E)T-HER --*—Other-]nformation - <br /> ❑ GEOPHYSICAL c } Surface Seal I�stalled ey: <br /> r PUMP INSTALLATION: Contractor F / <br /> P.- <br /> Type of Pump <br /> j P 11 State Work Done <br /> UMP REPLACEMENT <br /> ❑ <br /> PUMP REPAIR: State Work Done <br /> i <br /> Well Diameter � Approximate Depth <br /> DESTRUCTION OF WELL: <br /> ft Describe Material and Procedure <br /> fared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prep pp <br /> ordinanceStstate 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 /> Contr ica or's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> y �,:✓pe"Irr±it•.is iss{ed, I shall employ persons subject to workman's compensation laws of California." <br /> it Grout Ins ection prior to grouting and a final inspection. <br /> Title: Date: <br /> Sig (Draw Plot Plan on Reverse Side) <br /> FOR D PARTM T USE ONLY q <br /> PHASE I Date �/ <br /> Application Accepted By <br /> Additional Comments: <br /> Ph se III Final Inspection <br /> Phase 11 Grout inspection / <br /> Inspection By <br /> Date Inspection By <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July eceiv REMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> f <br /> FEE <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7 <br /> Permit NO. Issuance Date Mailed Delivered <br /> Received 6y Date Receipt No. - - `.. _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601-E.HAZELTON AVE., _Box 2009 570CNTON A 95201 <br />