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ppllcalionsWill BeProcessed,When Submitted Properly Completed. Be Sure To Sign The Application. w �~ -1 <br /> FOR OFFICE USE: F APPLICATION <br />+ A (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> PUMP&WELL <br /> - (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i 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 Cpunty Ordinance No. 186 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address r <br /> City/Town <br /> Owner's Name , <br /> I Address E Phone <br /> Contractor's Name y ti City J <br /> License#' i�,{�`d Business Phone <br /> Contractor's Address ' i .Emergency Phone ! �� f <br /> Is Certificate of Workman's Compensa ion Insurance on File With SJLHD? Yes — No <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN 11RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER;❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT,S' PUMP REPAIR <br /> '; �" <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> 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 ❑ CABLE TOOL <br /> ,DOMESTIC/PRIVATE 13DRILLED Dia. of Well Excavation <br /> [1DOMESTIC/PUBLIC Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL - TYpe of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> —41 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H,P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: 'r <br /> 0,State Work Done77 <br /> { <br /> DESTRUCTION OF WELL: . - Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure ��J <br /> I hereby certify that I have prepared this application pphcation 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 /> Homeowner 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 of sub-'contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout inspection prior to grouting and a final inspection. 1 <br /> Signed XTitles �` r+ <br /> Date: <br /> (Draw Plot Plan on averse Side) <br /> F <br /> PHASE DEPARTMENT USE ONLY <br /> Application Accepted By r , �-- <br /> Additional Comments: ` Date V <br /> Phase II Grout Inspection Phas IH F al Inspection <br /> Inspection By Date Inspection By Date 7�• # <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH' ti <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By'Juiy 31 <br /> I BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ <br /> DATE AMOUNT DUE CHECKED <br /> :r � DATE REMITTED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY t t <br /> OTHER I <br /> OTHER k, <br /> 4 <br /> 4 <br /> �-- <br /> Received by Date Receipt No. Permll'NQ. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date -Mailed D red <br /> TO <br /> I 1fipY E.HAZELTON AVE.,P.O.Box 2009 S OCKTON,CA 95201 <br />