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Applications Will Be Processed When SubmittedProperlyComplerea. ne oure 1aalyn 111empFl <br /> "2. _'``�' : APPLICATION <br /> FOR�OFFICE USEy, �p <br /> Cdlt✓-� (For Non-Transferable, Revocable, Suspendable) <br /> VVV PUMP&WELL <br /> 'II ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe 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 a d the rules and regul tions of the San Joaqui Lo al ealth District. <br /> Exact Site Address iN "� City/Town <br /> Owner's Name I� t Phone <br /> r Address �� �yty <br /> E_ Contractor's Name <br /> ' License# / . Business Phone <br /> Contractor's Address .-O X Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fi�WithD? Yes_ �. No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11OTHER ElPUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 11 %.! <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines', Pit Privy <br /> fSewage 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 /> r ❑R DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION 11 ❑ Ty <br /> GRAVEL PACK j pttr of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER i Other Information <br /> # ❑ GEOPHYSICAL. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P, 3 G <br /> F PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: !� State Work Done <br /> k <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dep h' <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 /> ordinan'Ces, 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 for which this <br /> permit is issued, I shall employ persons subject to workman's;compensation laws of California." <br /> I w#1 call for a Grout Inspec' n p 'or o gr ling and a final inspection. <br /> E ` Date: 7" <br /> I[ Signed Title: <br /> !� (Draw Plo Plan on Reverse Side) <br /> R DEPARTMENT USE ONLY 1 <br /> �. PHASE I �! <br /> Dat zL <br /> Application Accepted By <br /> Additional Comments: <br /> I i$ Phase II Grout Inspection Phase 111 Final Inspection <br /> 1111 Inspection By Date Inspection By Date <br /> Fee Is Due:l❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> l I BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> IDATE DATE REMITTED AMOUNT <br /> :P <br /> FEE <br /> LESS IfI <br /> ` <br /> PRORATIONIi� +1! <br /> PLUS v' <br /> PENALTY <br /> x OTHEROTHER <br /> is - <br /> 5IA - <br /> _ <br /> d Lb4S7 <br /> Delivered <br /> - ssuanc _ <br /> .9ceived by g`! - at <br /> Receipt No.. Perrn�t N _ _ i T <br /> ' PPLICANT—RETURN ALL COPIES-TO:'�"'ENi1RONMENTA-^-EAL-T PER�YiCo +.mow 16 <br /> Y -� ZEL ON <br /> Date Maile �rr� li <br /> 01_E..HA 'AYE.,O 6na'2D09�`S OCKTpY N;�A 95205 <br /> r- � <br />