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Applications Will Be.Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE-U "- APPLICATION <br /> -•---'"*�* (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address S Se G City/Town <br /> I / c� <br /> Owner's Name A.4 v V _.Phone �fG.�+ /��� 06 <br /> Address City <br /> Contractor's Name <br /> -oMW " � cense#a6 7-&94 Business Phone <br /> Contractor's Address � �3 Ci��f��l¢A6ol Emergency*Phonc S/hiA'Ye <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ♦w <br /> REPLACEMENT <br /> �y <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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia" of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED 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 Surface S al Instalfed By: <br /> PUMP INSTALLATION: Contractor ast `t f_ e ✓�.� ..�e� �..w. _. <br /> Type of Pump H.P. �yJ <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. <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 /> 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 /> I will call for a Grout Inspection prior to grouting and a final Inspection. <br /> Signed X {�+� � _ Title: a/7 ,P 1, Date: <br /> (Draw Plot Plan on Reverse Side) <br /> DEPA TMENT USE ONLY - = <br /> PHASE I <br /> Application Accepted By -�4 - �— Date <br /> Additional Comments: <br /> i <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 2rPER SITE ❑EACH ❑ Januar 1 a Received B Janua 31 <br /> Y Y ry ❑ July 1 &Received By July 31 <br /> BASE EXPLANATI BILLING REMITTANCE E <br /> REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION J <br /> PLUS <br /> +u <br /> PENALTY Z s Vv,/d t CGrJ- <br /> OTHER /•/ Oh t OSP. <br /> MVe!!__ sz V1,v r f <br /> OTHER 1 Tv t�ij adJreJ// MI — <br /> 0 cr~l' <br /> `SAeceived'Gy Date z Receipt No. Fermis No. r -I suance Date Mailed :. Delivered <br /> . <br /> APPLICANT—RETURN ALL COPIES TO:` .E H PERMIT/SERVICES 1601E HAZEL"TON•AVE.,P.O.BoM 20094+-aT0CKT6N,CA 95201 vY <br />