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n �^ Applications Will Be PR ocessed When Submitted Properly Completed.Be SureToSign TneAppucanvu. <br /> " E: APPLICATION <br /> FOR OFFICE <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY , <br /> (COMPLETE IN TRIPLICATE) I <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermiitoconstructand/orinstallthewark-Flereindescribed.Thisapplicationis � <br /> made in compliance with Sag Joaqul. County Or 'nance No.1862 and the rules and reguns of the San JoQquin �ocal el <br /> Health District. <br /> City/Town _ r � <br /> Exact Site Address <br /> x Phone <br /> Owner's Name <br /> City <br /> _ <br /> Address <br /> License i3usihess'.Phone <br /> f hr O <br /> Contractor's Nam <br /> Emergency Phone <br /> Contractor's Address No <br /> r- <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes _ <br /> TYPE OF WORK (CHECK): NEW WELL�DEEPEN ❑ O❑ ITI P <br /> DESTRUCTION' <br /> ORINATION 13 ❑ OTHER <br /> ❑P INSTALLATION ❑❑ PUMP REPAIR❑ <br /> WELL CHLWELL ABANDONMENT ' # <br /> REPLACEMENT❑ ��� r <br /> DISTANCE TO NEAREST: Septic Tank �_C� ewer Lines Pit Privy <br />` Sewage Disposal Fie�d- U <br /> Cesspool/IP <br /> epage Pit- Other <br /> Property Line j-�Private Domestic Well <br /> Q I <br /> ' INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL " -Dia- of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> El DOMESTIC/PUBLIC <br /> 7.- ❑ DRIVEN Gauge of Casing <br /> t� <br /> 13 IRRIGATION 0 l <br /> GRAVEL PACK Depth of Grout Sea <br /> ❑:CATHODIC PROTECTION .ROTARY Type of Grout <br /> OTHER Other Information <br /> ❑DISPOSAL <br /> r <br /> ❑}GEOPHYSICAL t sur{ace.Seal installed By:. <br /> PUMP INSTALLATION: Y Contractor Ily <br /> N. € t % i H.P. <br /> t- . Type of-Pump ; <br /> ❑ State Work e <br /> PUMP REPLACEMENT: k Don <br /> PUMP REPAIRS ❑ State Work Done T _ <br /> `�#Well Diameter ,,Approximates Depth' <br /> DESTRUCTION OF WELL: - e +t <br /> 41 -re Material and Procedure. } r +` <br /> I y ( ared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prep. <br /> ord'in_ances, state laws, and;rtiles.and regulations of the:San Joaquin Local Health District. <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 pers6ii'in-such manner as to become subject to workman's compensation laws of r.whornia." <br /> t. <br /> ,e <br /> +z Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this { <br /> permit is issued. I shall empl ersons subject to workman's compensation laws of California." r. <br /> I call fora Gr I s o pe r to.'routing and a final inspection. w - R- f ' <br /> t, <br /> x ! . ✓ -.Date: 1 <br /> S , I Title:- X <br /> y (Draw Plot Plan,on Reverse Side) ' ` 4 � <br /> FOR DEPARTMENT USE ONLY <br /> 1HASE I f ( Dale <br /> -Application Accepted By = <br /> } Additional Comments: '^ <br /> ( 4 Phas FinaInspection <br /> III l <br /> } { Phase II Grot ut Inspec o - � ; <br /> i �� Date InspectionNBy Date <br /> i t Inspection By <br /> _ f TJ.ly" <br /> �. + . � <br /> ,❑ PER SITE ❑ EACH ❑ January 1:8 Received t3y'January�31 '"❑ July 1 &Received Sy July 31 <br /> Fee Is Due:'❑`ANUALLY"`' ,❑ PER UNITN'.. -' ; - 4 REMIT j°_ <br /> i` REMITTANCE 1.$ -+ - >"'; MOt1NT DUE. CHECKED <br /> A <br /> y t BILLING ]- <br /> 1 BASE EXPLANATION DATE DATE i� REMITTED s AMOUNT A <br /> FSE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r <br /> Lx. OTHER"` <br /> .a <br /> OTHER <br /> r S^� <br /> . Permit NO ,ti. +.., ,� Issuance Date. .Mailed Delivered <br /> Received by .. - Date Receipt No <br /> 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCK70N,CA 85201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />