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Applications WIII Be Processed When Submitted Properly Completed.Be Sure o <br /> APPLICATION <br /> FOR OFFICE USE: ® ( <br /> For Non-Transferable, Revocable, Suspendabie) PUMP"&WELL. <br /> ENVIRONMENTAL HEALTH PERMIT t� <br /> R UALITY l 4 3 r 2 Ste~`� I <br /> (COMPLETE IN TRIPLICATE)99.9jsS--C–aG(t;FE +�-,�-�mi <br /> Application is hereby made tothhis <br /> eSanJoaquinLocalHealthDisiBfitrict{andor a pee rulosondretulatdionsofttheS nJoaquinLocalHeatlhTDistrict. tion is <br /> made in compliance with San/J�aquin County Ord a City/Town <br /> Exact Site Address ��u-T" 4 JB�� �,a M` <br /> e. VL Phone <br /> Owner's Name r City <br /> Address r <br /> ,.�. ,4 f� Icense# Business Phone <br /> Contractor's Name mergency Phone <br /> Contractor's Address No <br /> TION <br /> Is Certificate of Workman's Compensation Insurance on File With SJ D? Yes E <br /> TYPE OF WORK {CHECK}: NEW WELL❑ MENT ❑DEEPEN ❑ OTHER <br /> 11 ITl PUMP 1NSDTALLATCON ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDON . <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank - Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Weil Casing <br /> IIS DOMESTIC/PRIVATE 1:1 DRILLED <br /> ❑ DOMESTIC/PUBLIC <br /> 13 DRIVEN Gauge of Casing , <br /> ❑ ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION <br /> r Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 1:1 DISPOSAL —4" 11 OTHER ; Other Information <br /> 13 GEOPHYSICAL IySurface Seal Installed By: q t (A y <br /> PUMP INSTALLATION: Contractor <br /> J <br /> H.P. <br /> Type of Pump ,,� , <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> i Describe Material and Procedure <br /> I: 1 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 1-ieceof the work alth District. <br /> owing. .1 <br /> y that in the performan <br /> j Home ed, I shalllcensed not employnany signature <br /> n in such mannerlas t.becomesubjectto workman's compensation�aws of Califor which this rnia." <br /> is issued, I s <br /> I , Contractor's hiring or sub-contracting signature certifies the folloviring:"I certify that in the performance of the work for which this <br /> t to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subjec <br /> j 1will all toy a Grout Inspection prior to grouting and a final inspection. - <br /> Date: <br /> Title: <br /> Signed X r "' Dra an on Reverse Side) <br /> z f <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE 1 ". Date <br /> Application Accepte y <br /> Additional Comme ts: 4 t <br /> ha a III Final Inspecion p <br /> Inspection By Date <br /> t (� C6C6 L <br /> Phase II Grout Inspection Date <br /> Inspection By <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By;July 31 %I <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT; <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED 4 y <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE J <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S� Mailed De4ivered <br /> Received by Date Receipt No, <br /> Permit No. 1 uance to _ <br /> '1601 E.Hp,ZELTON AYE..P.O.6n■2009 570CKTON,C1�9501 - s� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICE5 �� <br />