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Applications Will Be Processed When Submitted Properly Combr4jd. Be Sure To Sign The Ap�lQ ion. I I L I <br />FOR OFFICE USE: APPLICATIOt t 11 - �97g � <br />s e <br />(For Non -Transferable, Revocable, Suspend <br />PUMP & WELL I <br />ENVIRONMENTAL HEALTH MAQUIN LOCAL <br />000 <br />(COMPLETE IN TRIPLICATE) WATER QUALITY . HEALTH DISTRICT 40* <br />Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described. This application is <br />made in compliance with,6ayrJn CntxdIn�aYnce�186 and the r es and regulations of the San oa uin��HHea tt h District" v <br />Exact Site, C��j �/� ��'y r - Lam, City/Towz-1-6 j d �rj�J <br />Owner's Name! " "P� >J �T �� ` Phone "T <br />Y <br />Address �-7Z 6 T City ✓ <br />Contractor's Name 7` � 5 License #/Z Business Pho <br />Contractor's Address " �� Emergency Phone <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 CJ--- PUMP REPAIR , <br />REPLACEMENT ❑ �` �,j F <br />t <br />DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />:Sewage Disposal Field--_.. .��., ..Cesspool/Seepage�Pit. L.._ Other <br />Property Line Private Domestic Well Public Domestic Well <br />INTENDED USE TYPE OF WELL <br />❑ INDUSTRIAL ❑ CABLE TOOL .. Dia" of Well Excavation e <br />❑ DOMESTIC/PRIVATE ❑ DRILLED 11pia. of Well Casing <br />© DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br />❑ IRRIGATIONS '"" ❑ GRAVEL PACK__Depth of Grout Seal <br />❑ CATHODIC PROTECTIONS❑ROTARYType of Grout <br />❑ DISPOSAL ❑ OTHER Other Information 1. <br />e � <br />❑ GEOPHYSICAL d Sltrface',Pal InstallPri Rv, <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />Contractor <br />Type of Pump <br />®'State Work Done <br />❑ State Work Done <br />Describe Material and Procei <br />I hereby certify that I have prepared this application and th <br />ordinances, state laws, and rules and regulations of the San <br />e work will be done in accordance with San Joaquin County <br />loin 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 />con'racto ' ring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this <br />perm sued, I shall e loy persons subject -fo-workman's c6mpen ion Paws of California." <br />E i rout In ec ion prior to grouting and a final in;spec n. J <br />Signed XTitle. <br />•' Date" <br />(Draw Plot Plan on Reverse Side) <br />F R DEPARTMENT <br />SE ONLY <br />PHASE I <br />Application Accepted By <br />Date G <br />7/q <br />Additional Comments: <br />Phase II Grout Inspection <br />Phase III Final Inspection <br />Inspection By <br />Date <br />Inspection By Date <br />Fee IS Due. ❑ ANNUALLY <br />❑ PER UNIT 1�r PER SITE ❑ <br />EACH <br />❑ January 1 & Received By January 31 ❑ July 1 & Received By July 31 <br />BASE- <br />EXPLANATION <br />BILLING <br />REMITTANCE <br />$ <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEE <br />% /- <br />s J <br />LESS <br />PRORATION <br />}_� <br />PLUS1 <br />PENALTY <br />2A' <br />OTHER <br />1 <br />OTHER <br />_. <br />Gi <br />1 <br />Received by Date <br />Receipt No. <br />. Permit No. <br />- Issuance ate Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO, ENvi R ONMFNTAI HFAI TM PF n MIT1CFpvlr:FC <br />�um-C-ue7Fl Ynu nVF'�o n -a.,. onew• rnrvsnu .v�eaey <br />J <br />