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Applications Will Be Processed When Submitted Properly Completed. Bsure Io bign ine <br /> =1PLICATE) <br /> APPLICATION <br /> {For Non-Transterable, Revocable, Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> fl TER QUALITY �7 _ O�rtD-37 <br /> i `2 �Lr F� g C. + <br /> Application is herebymadetoth�SanJoaqulnLocalHealthDisti-tf raper Ittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> ��rr /rr � l > 'e City/Town <br /> Exact Site Address4.15 <br /> 4 <br /> • ��, �� - _ �^ Phone <br /> Owner's Nam City / <br /> Address s F- [?,��$�E•, <br /> f� <br /> LLicense#� Business Phone <br /> Contractor's Name <br /> Contractor's Address mergency Phone <br /> 0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r <br /> TYPE OF WORK (CHECK): NEW WELL�DEEPE�N 13 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT � OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA{R❑ <br /> REPLACEMENT❑ *-j 'sz / Pit Privy fl <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Other <br /> Sewage Disposal Field Cesspool/Seepage Pit -0 r <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TY OF WELL /? <br /> ❑, UU TRIAL ABLE TOOL Dia. of Well Excavation <br /> IN <br /> L1J�0 E.5-]C/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r© <br /> 01RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> -49 <br />` ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL S rface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor � Y't ? <br /> Type of Pump H.P. (� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done O 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> Describe Material and Pro edure Ur <br /> I hereby certify that I have prepared this appli son 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:"1 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 for a Grout Inspe fon rior_to grouting and a final inspection. <br /> Title: Date: <br /> Signed X <br /> L (Draw Plot Plan on Reverse Side) <br /> �Y FOR DEPARTMENT USE ONLY <br /> PHASE i 1 r Date <br /> l ' Application Accepted By <br /> Additional Comments: <br /> { a 11 Grout Inspection. a III Final Inspection u Q <br /> , Date Inspection By Date ` <br /> - <br /> Inspection By <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT El SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED, AMOUNT <br /> FEE C-S <br /> LESS 1` <br /> I PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1` . <br /> OTHER <br /> o oIs, <br /> Received by " <br /> Date Receipt No Permit No. w Issuance Date Mailed �Oelivered•x��.+� Ir <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES - 1601 E.HAZELTON AVE.,P.O.Baa 2609 STDCKTt�CA 95201 <br />