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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> .FOR OFFICE USE: APPLICATION � f1" ,,-W. <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ' WATER QUALITY <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 <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rule_s and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 7nz1-' City/Town ZR�i/F�2 } ` <br /> e �.�j L� /���i � .� Phone <br /> f� <br /> Owner's Name � <br /> :,Address / A/ zzC y ;e_212;e_212 _ City <br /> Contractor's Name %: �C> Ifs✓- � % L+r/ r License#V , - Business Phone —/ _ <br /> Contractor's Address Vop" o Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes i�E No j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPENS RECONDITION❑ DESTRUCTION❑ <br /> 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 /> Rroperty Line- Q--Private-Domestic.Wel I - • -Public-.Domestic Well--.- "� ---- - -- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 9 CABLE TOOL Dia. of Well Excavation i <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ti ar , <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f , <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. N <br /> PUMP REPLACEMENT: ❑ State Work Done _ L2 <br /> PUMP REPAIR: ❑ StaC'e Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . f; <br /> Describe Material and Procedure (A <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 /> Home owner or licensed agent's signature certifies the following:"i certify that in the performance of the work'for#hich this permit CtI <br /> s <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." f" <br /> Contractor's hiring or sub-contracting signature certifies the iollowing: '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." I <br /> I w'I call for rout I7,111tprior to grouting and a final inspection. + ' <br /> I . <br /> Signed X --•�-� Title: Date: <br /> (Draw Plot Plan on Reverse Side) s <br /> FOR EP ART ENT USE ONLY 3 <br /> PHASE 1 Wr w j <br /> Application Accepted By " ' S `` {` Date p <br /> t <br /> Additional Comments: <br /> Phase 11 Grout Inspection,,// P e I Final I ection'" <br /> Inspection By Date//�� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED s AMOUNT o <br /> FEE <br /> LESS <br /> PRORATION G1! <br /> i <br /> PLUS 1 <br /> PENALTY a <br /> OTHER <br /> OTHER <br /> 5373 /a-p i <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed Relive tl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICEZF <br /> S 601&HAL/}ON AVE.,P.O.Box 2009 ST OC TON,CA 95201 �, <br />