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Applications Will Be Processed When Submitted Properly amp �-g- <br /> APPLICATION 1 <br /> FOR OFFICE USE: (for Non-Trans pevocalile;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY.. a . r rr'.1 ihSL�� �t> r <br /> wt �� plication is <br /> (COMPLETE IN TRIPLICATE) <br /> b made to the San Joaquin Local HealthDistrictforapermittoconstructand/ ofttheSa oroaquin'LocalHealdthDistrct <br /> i. <br /> Application is hereby <br /> made in compliance with San Joaquin County Ordinance No.1662 and the rules-and regulations City/Town <br /> Exact Site Address <br /> f .. Phone- oCl <br /> Owner's Name s : ; City <br /> Address License 4� -� r Business Phone` <br /> r Contractor's Name _ _ .,. •� Emergency Phone <br /> Contractor's Address r No - <br /> is <br /> o ,. <br /> I is Certificate of Workman's_Compensation Insurance on File With SJLHD? v Yes , <br /> TYPE OF WORK (CHECK):- NEW WELL❑ DEEPEN ❑-`"f RECOND1710N❑ DESTRUCTION^❑ SUMP REPAIR❑ " <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION LSA <br /> REPLACEMENT 13 Sewer Lines Pit Privy - <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/seepage Pit Other <br /> Sewage'Disposal Field Public Domestic Well <br /> i Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> IN TRIAL Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 11 GRAVEL PACK Depth of Grout Seal <br /> 13 IRRIGATION Type of Grout <br /> CATHODIC PROTECTION [3 ROTARY <br /> Other Information <br /> 13 DISPOSAL. 11 OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICALq <br /> I PUMP IN Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT:. ❑ State Work Done - ~ <br /> I PUMP REPAIR: <br /> [I State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> 4 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 /> } Joaquin Local H <br /> ordinances, state laws, and rules and regulations of the San ealth District. �• <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> S t to workman's compensation laws of California." <br /> is issued, I shall not employ any person in such manner as to become subjec :: x <br /> C <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> ject to workman's compensation laws of California. <br /> permit is issued, i shall employ persons sub " ry { <br /> I Will call Grout in tion prior to grouting and a final inspection. ' C <br /> I Daie:- L <br /> Title: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE.1 Date <br /> Application Accepted By <br /> Additional Comments: " phase 11 Final Inspection J �G �1 <br /> Phase 11 Grout Inspection ate , ' 1 <br /> f• Date Inspection By <br /> Inspection By <br /> I { <br /> Fee Is Due: El ANNUALLY PER UNIT ❑ PER SITE ❑ EACH, '--❑-January 1&Received By January 31 'C]July t &'Received By July <br /> REMIT' <br /> REMITTANCE $ AMOUNT DUE CHECKED--' <br /> BILLING REMITTEDR s AMOUNT <br /> BASE EXPLANATIDN DATE DATE' a <br /> FEE <br /> LESS <br /> I PRORATION i <br /> t- PLUS - - - • <br /> PENALTY f <br /> OTHER <br /> oT4iERY <br /> ' Permit No. .ayry I uance ate Mailed Delivered , <br /> Received by – � :'-Date _ <br /> ' APPLICANT—RETUpN ALL COPIES TO: pNYIAONMENTAI HEALTH PERMiT/SERVICES - „„µ;;R16�1�E_HAZEL-TON`AYE.,•P.O.9oa.20�4�5TOCKTOlI;CA95201- <br />