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r" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> I (For Non-Transferable, Revocable,Suspendable) <br /> �. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)S� 7 7 6,'4 �f,,, <br /> UaLITr <br /> Application is hereby made to the San Joaq cal Health Di to construct and/or install the work herein described.This application is <br /> made in compliance with an Joa n Ordinance No. 18621 and the rules and regulations of the San,J oaquin Local Health District. <br /> Exact Site Address 4 /t G NOL ai 14 City/Town _CSC�1�L O� <br /> Owner's Name yp <br /> t Phone Osie- 31 <br /> f Address "e city ZSC A)-0,7) <br /> F Contractors Name • +lam- Su -✓ License#a Business Phone AJ <br /> Contractor's Address C20C13 1*7;ql'Al Emergency Phone SA rn ac <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X/M No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRJR <br /> REPLACEMENT❑ V� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V' <br /> Sewage Disposal Field w 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 'I ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 1$ State Work Done 11. 4 I S <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />` Describe Material and Procedure <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />` I will paq for a Grout Inspection prior to grouting and a final t <br /> inspecio <br /> . ._..- <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted By Date �y 7/ <br /> Additional Comments: <br /> Phase II Grout Inspection Phas FiJInsoctionInspection By Date Inspection By ate / <br /> Fee is Due: ElANNUALLY ❑ PER UNIT 13PER SITE ❑ EACH ❑ January 1 &Received By January 31uly 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED -AMOUNT DUE CHECKEp <br /> AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ° - <br /> t <br /> OTHER <br /> 7 <br /> 6S-s--P-- ' ,Z_ <br /> `'1 t`a 7 <br /> ' Received by ate; Receipt No. Permit No. Issuance pate- Mailed vered <br /> ;_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16D1 E._HAZELTON AVE.,P.O.BoCKTON,CA 95201 <br />