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Applicati4ps Will Be Processed When Submitted Properly Completed.BeSureTO�i�J <br /> APPLICATION lko-0_�-- <br /> FOR oFFif: USE: tin <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT '{,�/l Y. l <br /> (COMPLETE IN TRIPLICATE) �'Ce�I77 S. if �,4 WATER QUALITY , ... �catk her? Cess <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or i.nstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin CounI ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name C�' - *r' City <br /> Address ,1 f <br /> �� ,r f� y "License#�— Business Phone <br /> I Contractor's Name _1 —� , _� P <br /> Emergency Phone <br /> Contractor's Address No <br /> 15 Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ � <br /> ❑ <br /> TYPE OF WORK (CHECK): NEW WELL ONME DEEPEN❑❑ OTHER P IN <br /> ALLAT ON� PUMP REPAIR .moi <br /> a WELL CHLORINATION ❑ WELL <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Cess oo1/Seepage Pit Other <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Weil <br /> I INTENDED USE TYPE OF WELL l <br /> INDUSTRIAL 459 �C�9Y1 11 CABLE TOOL Dia. of Well Excavation <br /> 1 <br /> ❑ DOMESTIC/PRIVATE <br /> 11 DRILLED Dia. of Well Casing <br /> ❑ '13 DRIVEN Gauge of CasingOf <br /> DOMESTIC/PUBLICD ,, <br /> ❑ Ito GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION syr <br /> F 11CATHODIC PROTECTION <br /> 11 ROTARY Type of Grout <br /> ❑ OTHER Other Information i <br /> { ❑ DISPOSALlled By: a raperf <br /> El GEOPHYSICAL Surface Seal instai <br /> PUMP INSTALLATION: Contractor <br /> rH.P. <br /> Type of Pump ; <br /> PUMP REPLACEMENT: ❑ State Work Done i. <br /> ' PUMP REPAIR: ❑ State Work Done l `� <br /> ' Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I her certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t .� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ."� <br /> }come owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Twill call for a Grout Inspection prior to grouting and a final inspection. r <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) e� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ,� Date <br /> i <br /> Application Accepted-By <br /> Additional Comments_: _ _ <br /> Phos 11 Grout Inspectio Phase III Final Inspection <br /> Inspection By <br /> ate� � v Zr Inspection By Date <br /> ❑ January 1 &Received By January 31 ❑ July i &Received By July 35 <br /> Fee Is Due: ❑ ANNUALLY M © PER ACH anu <br /> UNIT ❑ PER SITE - REMIT <br /> BILLING ITTANCE. $ AMOUNT DUE CHECKED <br /> -v BASE "'EXPLANATION DATE E REMITTED AMOUNT <br /> FEE <br /> LESS h <br /> PRORATION <br /> f <br /> PLUS 0 <br /> PENALTY -• ` <br /> OTHER <br /> OTHER <br /> t� <br /> Received <br /> -.� ate - Receipt o- Permit No. Iss ante ate Mailed Delivered <br /> ENVIRONMENTAL HEALTH PERMITISERYfCES. 1601 E.HAZFELTON AVE.,P.O.13v=2008 5TOCKTON,CA 9520 <br /> 'a�ICANT=RETURN ALL COPIES TO: <br />