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Applications Will Be Processed When Submitted ProperlyCompleted.`t� J � OTn'T1WApptl��rion. <br /> fJ <br /> FOR OFFICE USE: APPLICATION �, ��, <br /> (For Non-Transferable, Revocable, us1 n able) <br /> tT <br /> ENVIRONMENTAL HEALT MR 1951 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ti ' LCAL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct arSPNnsJEI.�nQb,iotlth (eihTescribed.This application is <br /> made in compliance v ySa�l�oa ty Or in nc 1862 and the rules and regulated, (AkhlHarQ In o�ll I t Di rices.., <br /> Exact Site Address / ��� City/Town <br /> Owner's Na e <br /> 0 .� fVJ37W` Phone <br /> Owner's Na7eAddress JV1�' City � � <br /> Contractor's Name U –5 License#� B si ess Phone, <br /> Contractor's Address 40t'! 7 _ Emergency Phone , 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes !!!!!! No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRE�' <br /> REPLACEMENT❑ <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 /> ❑,FNDUSTRIAL C3CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Q� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: gyState Work Done d�� <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 /> 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 Ing or sub-contracting signature certifies the following:"Ice f hat in the performance of the work for which this <br /> per is i ed I shall emplo pers ns subject to workman's compensate laws of California." <br /> I ill a or ut Inspecti pr' to gr u i and a final inspecti <br /> Signed X Title: Date. . <br /> (Draw Plot Plan on Reverse Side) <br /> '' FOR DEPARTMENT USE ONLLY�, 2 I <br /> PHASE I �lJ Date <br /> Application Accepted By It <br /> Additional Comments: At <br /> Phase II Grout Inspection ��/P se Final In ¢ection <br /> Inspection By— o Date Inspection By k" to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE J� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> of s 3Ill 1H <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO 01 <br />