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Applications Will Be Processed When Submitted Properly Completed. BeSure t <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL `^+ <br /> ENVIRONMENTAL HEALTH PERMIT '`� / �'�' AL2, <br /> .f�`7�? S [` Frru1 C�4.>!Jv WATER QUALITY 1,` �t ( �O-per <br /> (COMPLETE IN TRIPLICATE <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> 1862 and the and regulations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance No, <br /> City/Town <br /> Exact Site Address <br /> N Phone <br /> Owner's Name <br /> R. # City <br /> Address i r-/��� 10 1 <br /> t Lidense#,�� Business Phone "''r Y <br /> + Contractor's Name eel -- <br /> i I <br /> Contractor's Address Emergency Phone No <br /> Is Certificate of Workman's Compensatiori Insurance on File With SJLHD? Yes _ <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT E] OTHER ❑ PUMP INSTALLATION ❑ �PUMP REPAIR❑ <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 /> 11 INDUSTRIAL. 11 CABLE TOOL Dia. of Well Excavation <br /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,� GRAVEL- PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 DISPOSAL <br /> 11 OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal installed By: _, amemg <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done + `� <br /> 11 State Work Done <br /> PUMP REPAIR: p <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> , <br /> Describe Material and Procedure <br /> 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 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." \1 <br /> I will call fora ut nspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: �`S Date: <br /> (Draw Plot Plan on Reverse Side) \ <br /> FOR DEPARTMENT USE ONLY QQ�� <br /> PHASE 1 � ` Date ip. 1 <br /> Application Accepted B <br /> Additional Comments: - <br /> Phase II Grout Inspection Ph a III Final Inspection f <br /> Inspection By <br /> Date Inspection B Date <br /> fBy J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_z ❑ PER SITE ❑ EACH ❑ Janua"ry 1 &Received By January 31 E] July 1 &ReceivedREMITuIy 31 <br /> . ,BILLING REMITTANCE. ' $ AMOUNT DUE CHECKED <br /> BASE. .� EXPLANATION DATE DATE- REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> _ s <br /> OTHER , <br /> Date -� Receipt No �� Permit No. Issuance Date Mailed• Delivered + <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16x1 E.HAZELTON AVE.,P.O.POBox 2009 STOGKTON�GA 95201 <br />