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Applications Will Be Processed When Submitted arope <br /> Z 3 a' <br /> APPLICATION { <br /> FOR"OFFICO USE: ! <br /> (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I C)f 0 <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY �Lf3 -- -�5 <br /> Applicat4jsherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstallthework.herein described.This application is <br /> made in e pape}Nath San Joaquin CountyOrdinance No. 1862 and the rules d r g lations of the San Joaquin Local Health District. <br /> Exact Site; • u- r N City/Town s�idt� �� <br /> - ,' f Phone tJ a Jr— 9-7 <br /> I Owner's Name 2 a_ �5s ` <br /> City <br /> Address ,,,,te�n������� /� Jr <br /> License#�c71L�.� Business Phone <br /> Contractor's Namely <br /> Contractor's Addresses Emergency Phone <br /> )C No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes ` <br /> TYPE OF WORK (CHECK): NEW WELL P/ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ �1 <br /> REPLACEMENT❑ J. - <br /> Sewer Lines Pit Privy <br /> ' DISTANCE TO NEAREST: Septic Tank ,�� Other <br /> Sewage Disposal Field /00.41 Cesspool/Seepage Pit <br /> r <br /> Property Line Private Domestic Well Public Domestic Well <br /> k <br /> INTENDED USE TYPE OF WELL a <br /> 0INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> tia DOMESTIC/PRIVATE ❑ DRILLED a. of Well Casing <br /> E3DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing f� C <br /> r ❑ IRRIGATION GRAVEL PACK Depth of Grout Seat _ �Snoe� <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 Approximate Depth <br /> Describe Material and Procedure <br /> t, <br /> 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 Health District. <br /> Home owner or licensed agent's signature certifies the fallowing:"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 for which this <br /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout 1. spection prior to�(Dra <br /> ti �Plot <br /> and a final inspection. ; <br /> Title: G �' Date: <br /> Signed X S <br /> anon Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date ' <br /> Application Accepted By <br /> Additional Comments: <br /> P se 11 Gropt Inspection Phase Ili Final Inspection <br /> Inspection By Date <br /> Inspection By Date <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By,my 31 <br /> REMIT <br /> A-FEE <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 6tReceipt No Permit No. - Issuance Date Mailed Delivered <br /> rNLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKFACA <br />