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FOR OFF CE USE: / APPLICATION v <br /> ''1'ot (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> OMPLETE IN TRIPLICATE) WATER QUALITY <br /> ,plication is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> Tade in compliance with San Joaquin County Qrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> act Site Address OR I HfA f lti 1�1 City/Town 1 <br /> aRvnefs Name — <br /> (1 1 a. jv2 Phone I LY`q - <br /> address. city / r <br /> ntractor's Nis <br /> -me r^^+- License p Business Phone <br /> _ntractor's Address r ! Emergency Phone <br /> s Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes 0 <br /> `"PE OF WORK (CHECK): 7ELL <br /> RECONDITION❑ STRUCTIO <br /> :LL CHLORINATION ❑ ABANDONMENT OTHER ❑ PUMP INSTALL PUMP REPAIR❑ <br /> TcPLACEMENT❑ <br /> 11STANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit - Other <br /> Property Line Private Domestic Weltt� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Weil Casing <br /> ,! BLIC ❑ DRIVEN Gauge of Casing <br /> d )RRIGA - ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION - ❑ ROTARY Type of Grout <br /> r DISPOSAL ❑ OTHER Other Information __—_d <br /> GEOPHYSICAL- Surface Seal Installed By: <br /> MP INSTALLATION: - Contractor <br /> r - Type of Pump H.P. Z <br /> 'UMP REPLACEMENT: ❑ State Work Done <br /> "'MP REPAIR: ❑ State Work Don <br /> STRUCTION OF WELL, Well Diameter A roximate Depth <br /> Describe Material and Procedure,, U <br /> I hereby certify that I have prepared this application and that the evnirlil 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 <br /> alifornia"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 /> ill call for a Gr Ins tion prior to g ouWg-anf' //cti��on.in X )Kew Date:(Drerse Side) i <br /> FO DEPARTMENT'USE ONLY <br /> PHASE I <br /> Application Accepted Bye/� <br /> Additional Comments: <br /> a e II Grout Inspection r Phase III Final Inspection <br /> .. Inspection By Date /-/�"y ! �V Inspection By . I IL Date <br /> l <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> Wei BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE MW <br /> LESS - <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a. — <br /> OTHER <br /> 5 Ips Is _ <br /> Received by 'Dai Receipt No. Permit No. Issuance Date Mallen Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ram Tnu evc o n e.,.1. —niv— 1.-1 <br />