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ApplicationsWill Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLI CATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICAT(E] �. 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 San-Jdaqu' County Or . ante No. 1 fit and the rules and regulations of the San Jo quip ocaf Health District. <br /> Exact Site Address } City/Town , <br /> Owner's Name den, J�r Phone } <br /> AddressCity <br /> Contractor's Name _ Licens 91-f� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File'With SJLHD? Yes No f <br /> TYPI^OF WORK(CHECK);. NEW WELL"--DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �PUMP REPAIR � <br /> REPLACEMENT❑ it - , <br />}} DISTANCE TO NEAREST: Septic Tan <br /> P�• '74 Sewer Lines - Pit Privy -_e-Vert� <br /> k' Sewage dispnsal Fi+ - /;4: Cesspool/Seepage Pit . � Other 1 <br /> Property Line Private Domestic WellPublic Domestic well <br /> r INTENDED USE TYPE OF WELL <br /> lie <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation , <br /> E�'6 ESTIC/PRiVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOM' ESTIC/PUBLIC ❑ p#fI11Ehp; '� �I\ Gauge of Casing -i <br /> F_ ❑ IRRIGATION <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> 1:1 CATHODIC PROTECTION O'RMARY Type of Grout All, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> f © P <br /> GEOHYSICAL �I <br />?� •- Surface Seal Inst ed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: '❑ 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 lollowing:"I certify that in the performance of the work forwhich 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 suit-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 /> I will calk-or a Grout Inspection•prior to groutin and a final inspection: <br /> Signed X •Title• Date; <br /> r*[' 1 (draw Plot Plan on Reverse Side) y! <br /> 's R DEPARTMENT USE ONLY �■ <br /> PHASE <br /> Application Accepted By k <br /> ate' <br /> Additional Comments <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection eyT _ Date % _ inspection By - _ date <br /> Fee Is Due:❑ ANNUALLY ❑-PER UNIT PER SITE ❑ EACH ❑ January 1&RmeivO By January 31 ❑ Jufy 1 a ReLFiVVd By Juiy 31 <br /> REMIT <br /> aPi9E EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r <br /> SEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ` <br /> OTHER <br /> e7s <br />� rReceived by - _ Date - Receipt Na. -;Permit No s t Issuance Date an •Cativo I''i^; <br /> ' " p o <br /> y APPliCAHT,RET1iRH ALL^-COPIES TO: :ENVIRONMENTAL HEALTH PEpAAITlSER1fICES `-` ' - 6x� . CA 96L ., . . H 61-- <br />