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- Applications Will Be Processed When Submitted Properly Completed. <br />,4,, APPLICATION <br /> - -1-D-R OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j <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 5an J aquin Co y Ordin ce No. 1862 and the rules and regulations of the San Joaquin Local H Ith/�Istrict- <br /> Exact Site Address ' <br /> S;/D� City/Town [e".�C K v, - <br /> Owner's Name <br /> //Vj✓!� Phone 3s <br /> City <br /> Address <br /> Contractor's Name L14—V_"f RILL I&*nse#3��O Business Phone_ <br /> s t�� Emergency Phone <br /> z Tl�l>s <br /> Contractor's Address: ,.__ No <br /> ". Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION ElDESTRUCTION❑ . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION PUMP REPAIR C1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy n <br /> Sewage Disposal Field Cesspool/Seepage Pit Other , <br /> Property Line Private Domestic Well Public Domestic Well �. <br /> INTENDED USE <br /> TYPE OF WELL Q. <br /> 13 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> fid DOMESTIC/PRIVATE <br /> 11 DRILLED <br /> 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 I Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor ' ti✓I t't I <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> I Describe Material and Procedure <br /> LI 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 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 forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will l for Grou nspe ti prior to grouting and a final inspecti9q <br /> ki <br /> Signed X Tltle. <br /> 2 Date: , <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I rJ' Date <br /> g <br /> 1 �" <br /> Application Accepted By <br /> Additional Comments: <br /> { Phase II Grout Inspection % Ph a e III Fin Inspection /-7 <br /> Inspection By <br /> Date r Inspection By Date / <br /> F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> r DATE DATE REMITTED AMOUNT <br /> FEE ) 0. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> I OTHER <br /> OTHER <br /> Zs -�=3 <br /> Received by <br /> Date Receipt No. Pe it e. Issuance Date Mailed Delivered <br /> F APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 STOCKT¢N CA 96201- <br />