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n Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICCbst-. APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HE%LTHrIPERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Q <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework.herein described.This application is 7 <br /> made in compliance with an Joaquin County Or an a No.1 and the rules and regulations of the San Joaquin Local Health District. 0�1 <br /> Exact Site Address <br /> 5 — oZo City/Town JS_ CO2-i—O /V-- oz=-AG. CN <br /> rti— :5 ` ,F_r C, Phone <br /> Owner's Ng�1e © V <br /> Com. <br /> Address /,q< City CIS_ Gr'�,,4�a--6, <br /> Contract is Nam Dense# 366 Business PhoneL <br /> Contractor's Address -- Emergency Phone -An <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L— No <br /> TYPE OF WORK (CHECK): NEW WELL U�-_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 3—PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tan Sewer Sewer Lines � — Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �-^--r <br /> Property Line "" Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> MESTIC/PRIVATE ElDRILLED Dia. of Well Casing ! `� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> l <br /> ❑ CATHODIC PROTECTION NARY Type of Grout <br /> El DISPOSAL 13 OTHER Other Information > ; <br /> ❑ GEOPHYSICAL Surface Seal Installed By: S tM ` <br /> PUMP INSTALLATION: Contractor .r S:. o ^ <br /> Type of Pump H.P. 3 `r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. p <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit �1 <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 far which this p� \ <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> 'II call for a Grout sp n io ,o grouting and a final inspection. <br /> Signed X f Title: CAADate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f � <br /> Application Accepted By ® Datecl <br /> Additional Comments: <br /> l Phase It Grout Inspection se III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE xREMITTED AMOUNT <br /> / ^P <br /> FEE l <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> vered <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Der <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTOKTON,CA 95201 <br />