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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> T (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit San Joaquin County Ordinapce No. 1862 and the rules and regulations of the San Jo uin Lo al Health District. <br /> Exact Site Address L7 S. City/Town i <br /> Owner's Name SdD A Phone <br /> Address City <br /> Contractor's Name Z5,-,V '2 a r icense#,Z?2//�/ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes- X No <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank _ f _ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/ Pit •Other _ <br /> Property Line /'D Domestic Well Z�n t Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f1 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C 1J �� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information —� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: dz, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: © State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe 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. Q, <br /> Home owner or licensed agent's signature certifies the following:1 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 'gnature certifles the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall mpioy r ins subject to workman's compensation laws of California." <br /> I call for a out soecti 'p 6r to routing and a final inspection. <br /> Signed X Title: G/ k nc Date: <br /> (Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By r• Date <br /> Additional Comments: <br /> h se I Grout Inspection F]h a III Final Inspection <br /> Inspection By SC Date �"-��.1 Inspection By Datel;i�``S—S <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A�OaW <br /> Received by Dale Receipt No. Permit No. Issuarke Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 0OCKTON,CA 95201 <br />