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Applications Will Be Processed When Submitted ProperlyCompleted. Be Sure Iosign ine^ppu�uu� <br /> FOR OFFICE USE: APPLICATION j <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WEL,f,�_. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �'1, J, WATER QUALITY- q <br />€ (COMPLETE IN TRIPLICATE) � �00 N [ <br /> Application is hereby made to the San Joaq Din Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc No. 1862 and the rules and re ulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> x Phone <br /> E Owner's Na !' <br /> .L City <br /> Address �� <br /> j Contractor's Name LfJGLL /Lt/.v License#�j�ffl Business Phone_ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation 1nnsur on File With SJLHD? Yes No I� <br /> TYPE OF WORK (CHECK): NEW WELL 92 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �} <br /> WELL CHLORINATION ❑ WELL AIBl! NDONMENT 11 OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR❑ Cy <br /> I REPLACEMENT❑ 11 <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic lank f / <br /> j , J� — Other <br /> Sewage Disposal Field � Cess ooee <br /> e Pit <br /> ! Property Line%_J47_L Private Domestic Well I?A� Public Domestic Well <br /> INTENDED USE TOF WELL <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation 0 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DESTIC/PUBLIC 11DRIVEN Gauge of Casing � <br /> & IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION <br /> El <br /> Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: L Contractor <br /> H.P. <br /> Type of Pump <br /> 1 1 16' <br /> i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: +❑ State Work Done <br /> DESTRUCTION OF WELL: � Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> t I <br /> l hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> FFF ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agenPs signature certifies the following:"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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> R a Grout Insp ct' n pri r tl�grouting and a final inspec ' n. -ten <br /> I Title: w Date: <br /> 5E:!2 <br /> aw Plot Plan on Reverse Side) <br /> i I� <br /> I FOR DEPARTMENT USE ONLY <br /> IDate <br /> ted Byents: <br /> Phase 11 Grout Inspection ase Final'Inspection + ,\ <br /> f Date inspection By f Date 4 v <br /> Inspection By <br /> 1 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Sanuary 1 &Received By'January 31 ❑ Ju4y 1 &Recely d By REMITuly 31 <br /> ' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION y <br /> I PLUS <br /> i PENALTY <br /> OTHER <br /> OTHER �} }� <br /> Received by T <br /> Date Receipt No. Permit.No. Issuanc Date Mailed Delivered, <br /> �' APPLICANT RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITlSERViCE5 1601 E.HAZECTON AVE.,P.O.Box 2009 5T6CKTON'C A 95201 � <br />