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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> tg'1, -;(For�Non-Transferable, Revocable,Suspendable) � <br /> f-#} J PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 11/862 and the rule$And regulations of the San Joaquin Local Health District. <br /> Exact Site Address el C_ Z City/Town <br /> e y <br /> Owner's Name 13 La_ Phone <br /> Address r �-�S _ �c>. � �� - City . C c4 _ <br /> Contractor's Names .c G_ License / Business Phone c'— <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W6 SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ REC NDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION 7 PUMP REPAIR❑ <br /> REPLACEMENT❑ 11111 a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL © CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal l' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surfce Seal Installed By: 00 <br /> PUMP INSTALLATION: Contractor 11-1�L$lz4._1 <br /> Type of Pump H.P, t <br /> PUMP REPLACEMENT: X State Work Done <br /> PUMP REPAIR: ❑ State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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. <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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> al a r t Grout Inspec ion prior to grouting and a final inspection. <br /> Signed Title: C)n� raw _ _ Date: I `- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � 7 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> its <br /> 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _,;2 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deli r <br /> APPLICANT—RETURN ALL COPIES T1.O: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STO 7l CA <br />