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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,EOR CEFICE USE: t APPLICATION <br /> t <br /> (Far Non-Transferable, Revocable,Suspendable) <br /> c �J ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN,TRIPLICATE) 1 b WATER QUALITY <br /> t <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> ? made in compliance yvl h San Joaqui ounty Or ante No. 1862 and the rules and, regulations of the San Joaquin Local Health District. <br /> Exact Site Addres— r2 � � �,/!�F _ City/Town /-012 <br /> I <br /> Owner's Name 4. Phone <br /> Address I City;_.!�/C � <br /> Contractor's Name r License#'�Vaeov Business Phone <br /> Contractor's Address Ra, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No- <br /> C^J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 6_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> • . Property Line Private Domestic Well Public Domestic Well rZ <br /> INTENDED USE TYPE OF WELL <br /> r ❑ 'INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation -3 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing /4 <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 Surface Seal InstalVEly: <br /> PUMP INSTALLATION: Contracto- <br /> Type of Pump , Tc/a H.P. Z <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ;❑ State Work Done <br /> e <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. <br /> Homeowner 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 /> Contras is hiring or sub-contracling signature cerCfies the following:"I certify that in the performance of the work for which this <br /> i permi s issued, I shall employ perso s lett to workman's compen tion laws of California." <br /> I w' ca for a Gro I p,coon pr r t Wrouti ,and a final ins on <br /> 7 <br /> Signed X �' Title. Date: < <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEARTMENT SE ONLY <br /> PHASE I <i <br /> Application Accepted By 6,J Date 7 7� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> l Inspection By 1•ie Date Inspection By Date <br /> r-- Fee Is Due: El ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE - 'EXPLAN TION DATE DATE REMITTED AMOUNTDUE CHECKED - <br /> AMOUNT <br /> FEE r <br /> l LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER `a <br /> OTHER <br /> - <br /> - Received by _Date Receipt No. Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIcES '1601 E.HAZELTON AVE.,P.O.Box 2009 STOOCKTOM,GA 9vol <br />