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Applications Will Be Processed When Submitted ProperlyCompletea.tsesure vo+ylr I r•rr �- <br /> y- = APPLICATION <br /> "FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, 5uspendable) PUMP&WELL - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This apl—catbn Is <br /> made in compliance with San Joaquin County O :nano: _1!.;A862 d th r les and regulations of the San Jq jn Local Health District. . <br /> F City/Town <br /> Exact Site Address Q� <br /> Phone f <br /> Owner's'NameCity" { <br /> Address T } <br /> e Og 4 v-/_ Business Phone <br /> Contractor's Name Emergency Phone r1� <br /> Contractor's Address No ` <br /> Is Certificate of Workman's Compensation Insurance on File With SRECO Yes� �� <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN ❑ RECONDITION <br /> DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 1:1OTHER ❑ PUMP INSTALLATION1 PUMP REPAIR❑ <br /> REPLACEMENTPit Privy <br /> DISTANCE TO NEAREST: Septic Tank I Sewer Lines <br /> �" Cesspool/Seepage Pit Other <br /> Sewage Disposal Field „1 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation �y <br /> 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal j <br /> 11 ROTARY Type of Grout <br /> 13 CATHODIC PROTECTION <br /> ❑ OTHER Other Information <br /> ❑ DISPOSALi <br /> ❑ GEOPHYSICAL f Surface Seal installed 8y: <br /> PUMP INSTALLATION: i,Contractor <br /> Type of Pump H.P. <br /> 4. <br /> PUMP REPLACEMENT: <br /> K State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> �'�Well Diameter Approximate Depth <br /> I f Describe Material and Procedure Y <br /> T his application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that l have prepared t <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 toilowing:"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 ir`the performance of thework for which this <br /> t to workman's compensation laws of California." <br /> permit is issued, l shall employ persons subjec <br /> 'II call f r a Grourins eciion prior io grouiittg and a'final inspection. k <br /> Title! <br /> Dake: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPART SE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: ase III Final inspection <br /> Phase 11 Grout Inspection " <br /> I.rispection f3 Date �`�17- <br /> 11 Inspection By Date C/��y�; r <br /> 1 ❑ Januar 1 &Received BY J� an�uary 31 ❑ July 1 &Received By JuVy 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH y REMIT <br /> BILLING Y REMITTANCE $ AMOUNT DUE CHECKED <br /> .. BASE EXPLANATION DATE DATE REMITTED [� AMOUNT <br /> F FEE <br /> LESS t <br /> • PRORATION <br /> PLUS ' <br /> PENALTY <br /> k <br /> OTHER <br /> i. <br /> r OTHER <br /> —A,� 4.,wete--Mai—led— <br /> Deliv <br /> Received by <br /> Date Receipt No Permit No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009-: 570 ON,CA 9 201 <br />