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I ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> i�1:FOR OFFICE USIr- APPLICATION d i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> .ESI ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> .if ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY j <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No, 1882 and t e rules and regulations of the San J uin Local Health District, s <br /> Exact Site Address i2� J I� �pC�Ce City/Town a Ca <br /> [� <br /> �l, IQL[1-ion IS�e Phone <br /> Owner's Name p� 0 <br /> Address 5L ©ye '� e City <br /> Contractor's Name C H/ Drill License#`3 Business Phone Q 1179 Q <br /> Contractor's Address mil' Oc Emergency Phone <br /> Is:Certificate of Workman's Compensation In urance on File With SJLHD? Yes ft No <br /> T IPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION'N PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank o Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit <br /> Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ /01 <br /> CABLE TOOL Dia. of Well Excavation�� _ <br /> -9iDOMESTIC/PRIVATE DRILLED <br /> � Dia. of Well Casing <br /> ❑:DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d �L <br /> ❑ iRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION D�ROTARY } <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER <br /> Other Information <br /> Cl GEOPHYSICAL # Surface Seal Installed By: 4 to r <br /> PUMP INSTALLATION: Contractor e 1'"_to •t 14 <br /> Type of Pump 2, Hy XQ Milli <br /> H.P.— <br /> PUMP REPLACEMENT: ❑ <br /> State Work Done <br /> PLIMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth /O to <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. FFF <br /> Home owner or licensed agent's signature certifies the following:"I 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 forwhich this <br /> i I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i I will call for a Grout <br /> Inspection prior to grouting and a final inspection. <br /> Signed X Title: " <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pha a 11 Grout Inspection >Ia a III Final Inspection !� <br /> inspection By Date Inspection By Date W6 <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT NrPER SITE <br /> El EACH ❑ January Y &Received By January 31 El July 1 &Received By Juiy 31 4 <br /> ' BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> i FEE Al <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> I OTHER <br /> I <br /> OTHER <br /> Received by bate I Receipt No, Permit No. issuance Date - Mailed Delivered <br /> II' APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL-HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009' STOCKPON,C �� <br />