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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> FOR OFF E USE: <br /> t <br /> a. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMITw `� <br /> ,y f48`��17-05 <br /> (COMPLETE IN TRIPLICATE) GG 7?'7 S {U-+�t �`� WATER QUALITY A t,ana� / er ebC�' <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstruct /arinstaltheworkherelndescribed.Thi5applicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the,rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S City/Town <br /> ^ Phone ' " "4w! <br /> Owner's Name <br /> - City <br /> Address _ <br /> Contractor's Name � License# �- Business Phone— <br /> Contractor's <br /> i <br /> Contractor's Address - ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Y µ `�•�� <br /> TYPE OF WORK (CHECK): NEW WELCI)� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATiON 19 PUMP REPAIR❑ r <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank! Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I T Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE s TYPE OF WELL <br /> �i INDUSTRIAL - � ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ <br /> DOMESTIC/PRIVATE�Y r ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 1' GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 04 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. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done M ~ <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter _ <br /> r iDescribe Material and Procedure `J <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Y,-- <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> 1 <br /> llowing:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the to <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call for as Grout Inspection prior to grouting and a final inspection. ` <br /> Signed X Title. ��S Date: / L <br /> I (Draw Plot Plan on Reverse Side) <br /> G - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - Date " <br /> k Application Accepted By <br /> Additional Comments: - <br /> p e <br /> }: �Ph�se III Final In pection <br /> Grout Inspection <br /> Inspection By ` ate - L Inspection By Date LLL— <br /> ; <br /> Fee Is Due: EI ANNUALLY ❑ PLO UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Suly 1 &ReceivedREMIT <br /> BASE ! EXPLANATION BILLING Y REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a[J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER " r <br /> • <br /> Received by I Date Receipt No ' Permit No. -' isli Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1606 E.HAZELTON AVE.,P.O.Boy 2009 570CKTON,CA 95207 <br />