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Y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> s (For Non-Transferable, Revocable,Suspendable) PUMP&WELL I <br /> M ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY I <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconst ructand/or install the work.herein described.This application is <br /> t <br /> les and regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rua Health District. <br /> �(006 _�y+C� City/Town <br /> Exact Site Address>_ C, Q4 <br /> V �� Phone <br /> L <br /> Owner's Name a<l r r <br /> G� [? �^, .. � •, . city <br /> Address n/�� 5 # 'Business Phone Q <br /> Contractor's Name +. <br /> Contractor's Address _ �0 J Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> Noa <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP I�STALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ Ill") / �r <br /> Lines I�1t Pit Privy <br /> Sewer I <br /> DISTANCE TO NEAREST: Septic Tank ,� � .� Other N <br /> Sewage Disposal Fi Id Cesspool/Seepage Pit r <br /> Property Line lr J Private Domestic WellI V� Public Domestic Well <br /> INTENDED USE TYPE OF WELL / 4I 1 <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 Surface Seat Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I S <br /> f <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County C> <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. S <br /> Homeowner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit <br /> I not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> is issued, I shal4 <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 /> 1 till ca for grout inspection prior to r uting and a final inspection. �J_1L y/ <br /> W Title: �^.. '�` Date: <br /> Signed X C� <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ^^� <br /> PHASE I Date I+�� <br /> Application Accepted By t <br /> Additional Comments: <br /> Phase II Grout Inspection III Final Inspection <br /> Inspection By <br /> 41 <br /> Inspection By <br /> Date— � ` Date ""Z� <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT - ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &ReceivedJuly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` <br /> PRORATION <br /> Ir <br /> PLUS I <br /> PENALTY <br /> 8 <br /> i OTHER <br /> OTHER <br /> Received by <br /> D e - Receipt No. Permit No-- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1841 E.HAZELTON AVE.,P.O.Box 2049 5TOCIiTON,CA 95291 <br />