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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " CE USE: ,F, APPLICATION - <br /> +. (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL: <br /> ENVIRONMENTAL HEALTH PERMIT <br /> , ,rCOMPLETE IN TRIPLICATE} ATER QUALITY y } Q ) <br /> Application is hereby made to the an uin al Health istn t for a permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Jo quin County Ordinance No. 1.862 and the rules and regulations-of the San Joaquin Local Health District., G <br /> f Exact Site Address City/Town iJe YK PC2 <br /> t ^ <br /> 1 Owner's Name Phone�1 '? <br /> t Address Q <br /> City P,XLW art- <br /> Contractor's Name License# 7 7 4S Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce 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 REPAIR <br /> REPLACEMENT❑ r + J 1 <br /> " DISTANCE-TO NEAREST: Septic Tank -�-"`^' -Sewer Lines" �d Pit Privy--" <br /> Sewage Disposal Field Cesspool/Seepage Pit /®a r Other <br /> Property Line 6S/ Private Domestic Well Public Domestic Well <br /> i INTENDED USE TYPE OF WELL it <br /> [❑, iN�D STRIAL P-6-ABLE TOOL Dia. of Well Excavation�� 0 <br /> tk'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ] <br /> r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Art <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout to <br /> b ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ti Well Diameter Approximate Depth <br /> tDescribe 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 /> Homeowner or licensed agent's signature certifies the following:A 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will II for a Grout Inspe n-p for to grouting and a final inspec ona-ter- - - -- - <br /> Signed X Title: -I Dale: <br /> i <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Q Dated <br /> Additional Comments: <br /> . P a 11 Gro spection P a III Fina Inspection <br /> Inspection By Date Inspection By Date <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 - <br /> BILLING REMITTANCE $ REMIT <br /> - BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> v PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> z <br /> 1 <br /> l Received by Date Receipt No. Fermi Issuance Date, Mailed Delivered <br /> [ APPLICANT—RETURN ALL COPD TO: ENYIRONMENTAL HEALTH PERMI7ISERYICES 1 E.�H�AZELN_AV , P.O.Box 2009 STOGKTON,CA 95201 <br /> , <br />