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Applications Will Be ProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE-. APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMEENpTALiHEALTH PERMIT <br /> 11 LBRTF�IiQUAL <br /> (COMPLETE-M TRIPLICATE) ]] <br /> # <br /> Applid9fik n is hereby madeto theSan Joaquin Local Health Difir ict for a permit to constructand/or install the work herein described.This application is <br /> made in compliance.with San Joaquin County Ordinance N6. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (dare�v f: nrr s �,p�rwrj, /7 677. lir ,cow R4 City/Town ��QP.vt•�Cy�1�' � <br /> Owner's Name aJ 2 7'r ex. ��'�iZC^y, Phone � � 0 <br /> Address AsT�l.,, City 7�n-ck2NE-s� 1 <br /> Contractor's Name License# Business Phone <br /> Contractor's Address( &--Emergency Phone � �� <br /> Is Certificate of Workman's Compensation Insurance A File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r - <br /> DISTANCE TO NEAREST: Septic Tank. A-, Sewer Lines Acro —r Pit Privy <br /> 1 <br /> Sewage Disposal Field Ameg Cesspool/Seepage Pit Other <br /> Property Line ��_ Private Domestic Well .Public Domestic Well &A-4i•�t <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> # r? MRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 'L❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> f PUMP INSTALLATION: &w r µ.z 42, S! <br /> t !,TCyopi'tractor <br /> of Pump . �t+ f Aie onno c_ H.P. �r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> f —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 /> Y'Contractor's hiring orsubcontracting 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 call for a Grout Ins ion prior to grouting and a final inspectio . <br /> I <br /> Signed X Title: Date: <br /> • (Draw Plot Plan on verse Side) <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date— bra/ <br /> � <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection .. <br /> Inspection By- Date Inspection By C-t- Date 6f <br /> � -Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT _ <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE — <br /> s <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY t r <br /> OTHER <br /> OTHER <br /> 7eceived by Date .t Receipt No. _ Permit No. Issuance Date Mailed Delivered <br /> •APPLICANT=RETURWALL COPIES TO: 1 ENVIRONMENTAL HEALTH PERMIT/SERVICES "" 1601 E.HAZELTON AYE.,P.O.Box 2009 9TOCKTON,CA <br />