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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i FOR OFFICE USE: Carn APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �0 "mac` ,�: � "WATER QUALITY <br /> 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 an J aquin County Ordinance No. 1/862 ane <br /> ,r� rules and regulations of the San Joaquin ocal i-1621District. <br /> Exact Site Addres m8k1t 5d� D Off'/Dhb �°Okl�y- City/Town <br /> Owner's NamePhone <br /> Address IM' City <br /> Contractor's Name ;tom . I <br /> License#�:j 2_j^ Business Phone C Z. 7 7G <br /> Contractor's Address CA Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ fHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ , DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR j <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field SMI Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ fl <br /> 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 Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of`Graut <br /> ❑ DISPOSAL C1OTHER Other Information <br /> ❑ GEOPHYSICAL Surface'Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump H.P. AIR Z__ <br /> PUMP REPLACEMENT: ❑ State Work Done IM' <br /> RUMP REPAIR: ®.State Work Done <br /> DESTRUCTION OF WELL: WellDiameter IM <br /> Approximate Depth <br /> Describe Material and Procedure <br /> IM <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 mariner aslto become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies thelhfollowing:"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 /> 'I w'll call for a Grout.ln"speedo ri to g and a fine inspection. <br /> Signed XrS1�� 4i.. <br /> Date: �^ <br /> q (Draw Plo Ian n Reverse Side) <br /> ' <br /> F R PARFTMENT USE ONLY <br /> PHASEI <br /> _Application Accepted By Dat <br /> Additional Comments: `I <br /> Phase 11 Grout Inspection II a III Fipnspection <br /> Inspection By Date iL Inspection Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ '. REMIT <br /> BASE EXPLANATION il� AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �G II <br /> LESS 1 <br /> PRORATION <br /> PLUS k <br /> PENALTY oe <br /> OTHER <br /> + <br /> OTHER <br /> Received by Date Receipt No, Pfrmit No Is uan a Date Mailed Delivere�952 _ <br /> APPLICANT—RETURN ALL COPIES TO: - 'ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKT �{ <br />