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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> FOR OFFICE USE: APPLICATION -- <br /> cc (For Non-Transferable, Revocable, Suspendable) -� <br /> PUMP&WELL, s <br /> ENVIRONMENTAL HEALTH PERMIT \ <br /> { (COMPLETE IN TRIPLICATE) D7c� S„ tiJ �u1GsTt E QUALITY 70(- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is -3 <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health-District. �. <br /> Exact Site Address � ®"`I' �� City/Town - <br /> Gr <br /> Owner's Name p 2- Phone� ;-� <br /> Address n Cit <br /> Contractor's Name �l �� License# Business Phone Z <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workmah's Compensation I ur ce on File With SJLHD? Yes /Nc No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑- -PUMP REPAIR® } <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL, <br /> r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ! ; . <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing : - <br /> ❑ DOMESTIC/PUBLIC y I ❑ DRIVEN Gauge of Casing t ' <br /> 4 -IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4�_ <br /> 11 CATHODIC PROTECTION 1-1ROTARYType of Grout <br /> i ❑ DISPOSAL ❑ OTHER Other Information } t <br /> ❑ GEOPHYSICAL Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> y Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done _ <br /> i i.- 'A'pproximate Depth <br /> DESTRUCTION OF WELL:'-' -� Well Diameter_ , <br /> ~ 'Describe Material~and-Procedure <br /> I hereby certify that 1.l 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 /> r Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 /> t 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 sub"Je ' o workman's compensation laws of California." ' <br /> t Ill call for a Grout I tion r' o grou' an final inspection. <br /> le: Date: <br /> Signed it — <br /> (Draw Plo Ian on, Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I /J <br /> Application Accepted-By o Afi, <br /> Date <br /> I <br /> Additional Comments: <br /> Phase 11 Grojit Inspection Phase III Final Inspection - <br /> Inspection By e!_11 Date Inspection By Date <br /> T ,Fee Is Due: ❑ ANNUALLY ❑ PER UNIT . ❑ PER SITE ❑ EACH . ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedBy July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> ' <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> a � 7-7II y <br /> Received by -Date Receipt No. Permrk No. Issuance Date Mailed Delivered <br /> T APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM lT1SERVICES - 1601 E.HAZELTOk AVE,,P.O.Boa 2009 STOGKTOJ�1 .{t95201 - <br />