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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheAppucatlon <br /> FOR,OFFICE USE: APPLI AtION <br /> _,. !/ <br /> (For,Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> W TER G 1 Y_ <br /> (COMPLETE IN TRIPLICATE) rj -T4 S. � C jn� �' ' <br /> Application is hereby made to the San Jo quip Local Health Distrlct'f6ra permit o onstruct and/or i6 all thework herein described.This application is <br /> mane in compliance with San Joaqui unty O dlnance 1862and-the rules a``nd�/ regulations of the San Joaquin Local Health District. <br /> • `moo �. i" �� �G v�+a�- City/Town a <br /> Exact Site AddressPA <br /> R <br /> Phone F* - <br /> Owner's Name " c1!' cityd <br /> Address '-i7 <br /> j License#� ,� <br /> Contractor's Name <br /> Contractor's <br /> 6 � <br /> Contractor's Address r �a Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance-on Fil ith SJLHD? Yes- No r <br /> "DEEPEN ❑" RECONDITION❑` DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL❑' ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> G DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field *'Cesspool/Seepage Pit Other <br /> x Property Line Private Domestic,Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL c <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> DOMESTIC/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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ i SurfacerSeal Installed By: <br /> r3 c <br /> PUMP INSTALLATION: i Contractor - <br /> Type of Pump. <br /> - H.P. � <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: j® State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure.,: <br /> I <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 /> i <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, l shall not employ any,person in such manner as to becofne-subject to workman's,compensation laws of California. "L <br /> Contractor's hiring or sub-contract signature certifies the tollowing:"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 /> I i <br /> .I will call for a Grout Inspection pr to gro and a 'nal inspection. . <br /> ate: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> ' FOR DEPARTMENT USE ONLY - <br /> PHASE I `" r -- r' Date �� <br /> Application Accepted By <br /> Additional Comments: 5 <br /> "T Phase 11 Grout Inspection P a 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> f ' � <br /> Fee IS'Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH.' _i7January 1'& ec ed By January 31 a ❑ July 1 8 Received By July 31 1 <br /> REMIT <br /> BASE EXPLANATION- BILLING REMITTANCE $ AMOUNT DUE CHECKED -k <br /> DATE DATE REMITTED AMOUNT <br /> !F <br /> FEE <br /> LESS P <br /> PRORATION - - <br /> PLUS - - <br /> ` PENALTY. <br /> OTHER <br /> .� -.4 <br /> OTHER - <br /> . Received by - Date - Receipt No.' _F.: Permit No Is uance D to Delivered <br /> Mailed 1601 E.HAZELTON AVE.,P.O.box 2009 S7OCKTON,GA 95201 <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />