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Applications Will Be Processed When Submitted Properly Compl <br /> FOR OFFICEeted. Be Sure To Sign FThe Application. <br /> AUSE: APPLICATION <br /> ry (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> N .. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the.work <br /> made in compliance withherein described.This application is <br /> Exact Site Address . an Joaquin Count .Ordinance No. 1862 and.the rules and regulations of the San Joaq in Local Health District. i <br /> f � �' - _ y <br /> 'mac City/Town _�e�uer�•u <br /> Owner's Name — <br /> L st , <br /> Address Phone ; <br /> zY, v�ct <br /> Contractor's Name A IlkCity rzk-,% <br /> Contractor's Addres �° ' License# <br /> Business Phones Ef� �((J <br /> t ''' Emergency Phone' '.: . ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?_ c. <br /> TYPE F Yes No 4 <br /> O WOR �— _ <br /> K (CHECK)-. 'NEW WELL DEEPEN ❑� RECONDITIONu DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> OTHER ❑ PUMP INSTALLATION❑ <br /> REPLACEMENT❑ PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic.Tank S�wer Lines E- <br /> 4: Pit Privy �- <br /> Sewage Disposal Field•- 4 1 <br /> I J�� Cesspool/Seepage Pit �._,. Other �-- <br /> Property Line C7 Private,Domestic Well <br /> INTENDED USE c.�4- Public Domestic Well �— <br /> TYPE OF WELL :, <br /> ❑ INDUSTRIAL <br /> •: CABLE TOOL Diaof Well Excavation <br /> DOMESTIC/PRIVATE ;e Wli` j'\ ❑.DRILLED Dia. of Well Casing " R <br /> ❑ DOMESTIC/PUBLIC DRIVEN <br /> ti tt ._/Gauge of Casing _ [ c,;. coq W <br /> IRRIGATION `'O'GR.Y'EL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSALType of Grout <br /> 11 OTHER -Other Information <br /> 13 GEOPHYSICAL 1`'^ <br /> PUMP INSTALLATION: Su�fac�e Seal Installed By: - � t <br /> _ Contractor w`t 4- J. <br /> Type of Pump N❑ StaN.P.' <br /> PUMP REPLACEMENT. - <br /> ��- State Work Done Z, ty� <br /> PUMP REP ❑ <br /> AIR: ti r <br /> State Work bone ■ „� y. � , <br /> DESTRUCTION OF WELL: Well Diameter ~' <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepaeed 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 Healthibistrict. # <br /> Home owner or licensed agent's signature,ceetifies the following:"I certify that;in'thI performance of work forwh ch 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 signature certifies the following:"1 cwtiiy that <br /> Permit is issued, I shall ein the``performance of the work forwhich this <br /> m to ' <br /> p y persons subject to workman's compensa{ion laws of Califotrnia," - <br /> I will all fora rbut pec' n for togrouting-and a final inspection. <br /> Signed X "• f / - <br /> Title Date A <br /> (Draw Plot Plan on"14e i Side) <br /> FOR DEkRTINENT`USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: "`tti 5. f �.tDate fid= iii <br /> ase II rout Inspection <br /> Phase III Final Inspection : <br /> Inspection B Date—/ <br /> l '_Inspection 8, - Date - <br /> i <br /> Fee Is Due: ❑ ANNUALLY'' ❑ PER UNIT4' ❑ PER SITE ❑ EACH <br /> ❑,January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> DATE t DATE REM TIED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ' r�EI <br /> LESS @ L�5 O <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> Received by Date - y � ' <br /> Receipt No --°:� Permit No, A.4 -.v -.Is uance ate -- -4Mailed -Delivered. <br /> ' - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELT N AVE.,P.O.Box 2009 57pCKTON,CA 95201 <br />