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Appy rr r s d eD­ <br /> INJBVI <br /> itted Properly Completed.Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: ! <br /> PPLICATION <br /> 22Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> z9-QV1WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) I I <br /> Application is hereby made to the an �aq�ilnliea%istrictfor,apermittoconstructand/or install the work,herein described.This application is <br /> made in compliance w.ah.San Jp4quin Rounty.Ordinance No. 1862 and the rules and re Mations of the San Joaquin Local Health District. <br /> Exact Site Address L � Ce) City/Town <br /> Phone <br /> Owner's Name 1. <br /> s _ <br /> Address _ 5C) . , City. <br /> Contractor's Name Mac hc,,r n�.. { License# ��� Business-Phone a 'I I� <br /> Contractor's Address lir� `T6T\ Emergency P ne `I I'�2 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No - ' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ O <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines L 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 /> ❑ INDUSTRIAL ❑ 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 Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - -,i.. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Slate Work Done <br /> t PUMP REPAIR: 1 0 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 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 for which this <br /> permit is issued, I shall employ pe ons sub'ect to workman's compensation laws of California." <br /> 3 <br /> ill c for a Grout Inspec n rior t routing a final inspection. <br /> Signed X ' Tille: _ 'Date: <br /> g - ; (Draw of Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I ��;N Date <br /> Application Accepted By t <br /> Additional Comments: 4 <br /> Phase I Grout Inspection i I Phase III Final Inspection <br /> Inspection By Dale Inspection By '+%r Date <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ElPER SITE El EACH. ❑ January t &Received By January 31 ❑ July 1 8 Received By duly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I suance to Mailed Delivered <br /> Received by Date - Receipt No - Permit Na - - <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.8011 2009 5TOGKTON,CA 95201 <br />