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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICENJSE: APPLICATION a <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WLl. <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT 1 <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 an Jo qui C unt din nee No. 1862 a d the rules and regulations of the San Joaquin oG ealth District. a <br /> Exact Site Address City/Town S 165 <br /> Owner's Nam Phone 1 �0 W_�€ <br /> Address f n City <br /> S C <br /> -- Contractor's Name License# Business Phone <br /> L Contractor's Address Emergency Phone RUM�i <br /> Is Certificate of Workman's CompensationnInpurance on Fit ith SJLHD? Yes No <br /> f TYPE OF WORK (CHECK): NEW WELL.+ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank O Sewer Lines AJ� Pit Privy <br /> r Sewage Disposal.�Fi l _" / - Cesspool/Seepage Pit Other <br /> Property Lind`^,e J V � Private Domestic Well_-X)619 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE.TOOL Dia. of Well Excavation 12. 1 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing if <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ..CL <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CfJ tl�" <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout am <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> � Y <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 /> tttl <br /> Homeowner or licensed agent's signature certifies the fallowing:"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 persons subject to workman's compensation Laws of California." <br /> 1W all for a Gout I pection prior to groutin and a final inspection. v <br /> Signed X ►` Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By � Date <br /> Additional Comments: <br /> Phase It Grout Inspection Phase III Final Inspection <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 /> BILLING REMITTANCE $ <br /> BASE 'EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> M FEE U u <br /> LESS ��r ^} <br /> PRORATION 1:� I <br /> PLUS <br /> U. <br /> PENALTY - - <br /> OTHER V <br /> OTHER <br /> �A <br /> w. .. Received.by - Date £- Receipt No.�__ •w. -Permit No. Issuance Dat Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20 TON,CA.poi <br />