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ApplicationsWill Be ProcessedrWhen Submitted Properly Completed. Be Sure To Sign The Application. T <br /> s` FOR OFFICE'USE: APPLICATION <br /> {For Non-Transferable, Revocable, Suspendable) j <br /> ,E� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ,: <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r App`Iicationishereby madetotheSanJoaquin Local H6althDistrictforapermittoconstruct and/or install theworkherein described.This application is <br /> made in compliance with San Joa um Co n y 9 rdinan e No. 6 and the rules and regulations of the San J in LoPI ealt District. <br /> Exact Site Address <br /> � �� City/Town <br /> Owners Name f f <br /> r Address Phone <br /> City <br /> Contractor's Name icense# Business Phone _ <br /> Conliractor's Address -� Emergency Phone <br /> Is Ce rtificate of Workman's Compensation 19 urance on File With SJLHD? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELL®'� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WEAL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONPUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic TankSewer Lines_� •fi Pit Privy <br /> G Sewage Disposal Field Cesspool/Seepage Pit Other <br /> ^I Property Line/61-b Private Domestic Well :577 _ Public Domestic Well <br /> (INTENDED USE TYPE OF WELL <br /> ❑�INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> P-11OMESTIC/PRIVATE rd 0RILLE D Dia. of Well Casing13 <br /> DOMESTIC/PUBLIC ❑ .DRIVEN <br /> 47 <br /> IRRIGATION 1:1 GRAVEL <br /> of Casing g ; <br /> GRAVEL PACK <br /> F' � Depth of Grout Seal a `� <br /> ❑ CATHODIC PROTECTION t 9 RpTARYType ' Grout <br /> ❑ DIISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> #', i Contractor <br /> + Type of Pump <br /> H,P, <br /> PUMP REPLACEMENT: s, , ❑ State Work Done <br /> PUMP REPAIR: ❑ St <br /> ato Work Do � <br /> DESTRUCTION OF WELL., Well Diameter ', 1,`!Ail 10 b i ate Depth <br /> Describe Material and Procedure <br /> i_hereby certify that 1 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 /> Home owner or licensed agent's signature certifies the following:'1 certify that in the performance of thework forwhich 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 /> I permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I v <br /> j&call for a G ut spection prior to grouting and a final inspection. <br /> Signed Title: i� ����L��fi' Date: �10O� t <br /> (Draw Plot Plan on Reverse Side) <br /> ' FOR DEPARTMENT USE ONLY t <br /> PHASE <br /> F- <br /> Application Accepted By <br /> `e Additional Comments: k a Date ) _ <br /> h e to Inspection } <br /> r� � a Final lnspection <br /> Inspection By Date f`? �7 <br /> 's j I Pe Date <br /> QJ r ` <br /> Fee Is Due: ❑ ANNUALLY PER UNIT' ❑ PER SI�E ❑ EACH. }` r <br /> Ja 1 &Received By January 31 ❑ July 1 &Received By July 31 c <br /> j I BASE EXPLANATION. BILLING REMITTANCE $ REMIT - <br /> 'DATE AMOUNT DUE CHECKED <br /> oil - DATE REMITTED AMOUNT <br /> �E�FEE <br /> 'LESS i w <br /> PRORATION <br /> 'PLUS <br /> f PENALTY r - <br /> $ OTHER <br /> j MOTHER' r <br /> F I i <br /> .Received by Date <br /> Receipt No. Permit No. D <br /> I 1e Mailed Delivered <br /> uance <br /> EIih',APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 5 <br /> iP 70CKTON,CA 95201 <br /> —_ i <br />