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Applicationsplications Will Be Processed WhenaSrted Properly omp yj <br /> APPLICATION <br /> FOR-OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT :S <br /> WATER QUALITY application is <br /> Application is hereby madetathe San Joaqu <br /> (COMPLETE IN TRIPLICATE)" <br /> �n Local Health District fora permit to construct and/or install the work herein described-This app• <br /> made in compliance with San Joaquin Cou ty Ordinance No. 1862 and the rules and regulations <br /> oTownSan Joaquin Local Health District. <br /> Exact Site Address <br /> Phone ��� <br /> [[ Owner's Name fylr < City �T` <br /> I. Address License# Business Phone �I. <br /> Contractor's Name Emergency Phone <br /> Contractor's Address rr No Lo <br /> Is Certificate of Workman's Compensation insurance n File With SJLHD? Yes ❑, rw <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 RECONDITION❑ DESTRUCTION 11k. t11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> 11 OTHER C3 PUMP REPAIR❑ <br /> PUMP INSTALLATION �1 , <br /> REPLACEMENT❑ I Pit Privy Ut`�_ <br /> I Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit �E�t�!� Other <br /> Sewage Disposal Field"l 2M r J r i <br /> Property Line�f l lI Private Domestic Well Public Domestic Well <br /> rt <br /> TYPE OF WELL , <br /> INTENDED USE Dia. of Well Excavation ! <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> i 99—DOMESTIC/PRIVATE Gauge of Casing f ^Q <br /> E] DOMESTIC/PUBLIC ❑ DRIVEN Depth of Grout Seal <br /> I ❑ IRRIGATION ❑ GRAVEL PACK <br /> ❑ ROTARY <br /> € <br /> 13 CATHODIC PROTECTION Type of Grout !li <br /> E <br /> 13 DISPOSAL ' ❑ OTHER Other Information r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: k Q <br /> I <br /> eS <br /> Contractor .f>errI'll 111141 <br /> PUMP INSTALLATION: H.P. ~ <br /> �- Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done p <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: <br /> �� �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 /> t 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 /> � <br /> oy persons subject to workman's compensation laws of CaMornia." <br /> permit is issued, i shall emp <br /> I will call for a Grout Inrection prior to grouting and a final inspecti <br /> Title: ! Date: <br /> Signed X <br /> k Y (Draw Plot Plan on everse Side} <br /> F DEPART ENT USE ONLY <br /> PHASE 1 ;I Date <br /> I Application Accepted By !� <br /> Additional Comments: P ase,III Final Inspection <br /> Phase II Grout Inspection <br /> Inspection By L Date <br /> DZ� <br /> Inspection By p <br /> ,(/ at <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE El ❑ January 1 &Received 8y January 31 ❑ July i &Received <br /> July 31 <br /> EMIT - <br /> I - EXPLANATION BILLING REMITTANCE - $ '� AMOUNT DUE CHECKED <br /> BASE - DATE DATE REMITTED <br /> I AMOUNT <br /> k FEE <br /> 11 <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY ^I <br /> OTHER <br /> i�. <br /> -OTHER <br /> [ ' Issuance Date Mailed Delivered - <br /> ' Receipt No. Permit No. <br /> Received by Date - �, 1601 E.HAZELTONiWVE.,P.O.Box 2009 STOCKT�5201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SEF>.VICES l� <br />