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Jil Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FICE USE: APPLICATION <br /> Ci ► �� (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .WA11 TER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health District foir permitto construct and/or install the work herein describ rd.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 arld the rules and re Mations of the San Joaquin Local alth Di rict. <br /> Exact Site Address -,� !� Z;? City/Town <br /> Jr <br /> Owner's Name 0, SaX l Phone 0 ' <br /> Address / City- <br /> Contractor's <br /> i <br /> Contractor's Name III icense i mousiness Phone <br /> Contractor's Address AO Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With7RECONDITIONEl <br /> LHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR W <br /> REPLACEMENT❑ <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 /> ❑d INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> to DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC 0 DRIVE=N Gauge of Casingi <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal "�� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 4 Other Information <br /> ❑ GEOPHYSICAL a C Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 4, Type of Pump M. e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: R State Work Done e <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t <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. t <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 forwhich this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of California." i <br /> I Will call for a Grout Inspe nZ4, <br /> Ing and a final inspection. <br /> IG / i <br /> Signed �Iali_tole <br /> : /"+ Date: 1'' <br /> {Draw Pl 'Reverse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! <br /> Application Accepted,By Date <br /> Additional Comments: k' <br /> Phase 11 rout Inspection h se III Final Inspection <br /> Inspection By Date 4 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 /> BILLING REMITTANCE - $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 4 <br /> sFEE <br /> LESS ' <br /> PRORATION k .. <br /> PLUS <br /> PENALTY III <br /> OTHER <br /> OTHER+ ; <br /> s' <br /> Received by Date Receipt No. f� Permit No. Issuance Date Mailed De$ivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES . .1601 E.HAZELTON AVE.,P.D.Box 2009 S7OCKT0 <br />