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'- - Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -FOR OrFICE USE: f APPLICATION <br /> Lt co (For Non-Translerable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT vti <br /> '(COMPLETE IN TRIPLICATE) WATER QUALITY O <br /> Application ishereby made totheSan Joaquin Local Health Districtforapermit toconstructand/or install theworkherein described.This application is � ! <br /> 1 <br /> made in compliance with San Joaquin County Ordinance No. 862 d the rule and regulations of the San Joaquin Local Health istrict. <br /> Exact Site Address J City/Town ;?^i ?y C'A Ci <br /> Owner's Na me Phone <br /> I Address ;C."i AIA41— City_ <br /> Contractor's Name OW ` u- License#193-9Y!Business Phone_ <br /> t <br /> Contractor's'Address Emergency Phone <br /> ui <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes _ No <br /> 5 TYPE OF WIORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE 70 NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field rresspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMES TIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ! ❑ DOMES TIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION1:1GRAVEL PACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> a ❑ DISPOSAL ❑ OTHER Other Information <br /> a r <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ai Type of Pump '�✓ �� H.P. �rI , <br /> PUMP REPLIA CEMENT: El State Work Done <br /> l <br /> PUMP REPAIR: ❑ State Work Done <br /> it <br /> 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 /> i. ordinances, state laws, and rules and`regulations-of the Sgni.Joaquin Local Health District. <br /> <� <br /> Homeowner or licensed agent's signature certifies the following;"I certify that in the performance of the work for which this permit i <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k l ilw'I call for a Grout Inspny <br /> r to rou :g and a final inspection. <br /> Signed'X i isle: Date: e, <br /> (Draw Plot Plan-on Reverse Side) <br /> �I FOR DEPARTMENT USE ONLY <br /> I} PHASIE I <br /> a (L p <br /> Application Accepted By _ Date Z r Q <br /> Additional Comments: <br /> Phase II Grout Inspectionhese III Final Inspection <br /> i' <br /> ;i Iri spection By Date Inspection By Date 2 <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNfT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ji BILLING REMITTANCE $ REMIT i <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> a DATE DATE REMITTED AMOUNT <br /> � FEE <br /> 1 <br /> LESS F <br /> PRORATION <br /> PLUS 4 <br /> PENALTY _ <br /> 'EF OTHER( <br /> i I. <br /> } OTHER <br /> is }< <br /> _ <br /> {, iby Date Receipt No, Permit No. - - issuance Date Mailed Delivered , <br /> is <br /> klli�. APP IICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 9520-1 <br />