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Applications WIII'Be Processed When Submitted Properly Comp s ruaToSgn he pt1in. <br /> -FOR OFFICE USE: � �" APPLICATION �� n t <br /> (For Non-Transferable, Revocable, Suspenda�I.�p-C 8 I98Q <br /> PUMP&WELL f. I <br /> ENVIRONMENTAL HEALTH PNJ��TriY: <br /> u : LOCAL <br /> COMPLETE IN TRIPLICATE WATER QUALITY HEALTH DISTRICT <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 Cou ty Ordinance No. 862 d t e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town -I-I��,Q$ !b <br /> Owner's Name Phone <br /> Address City <br /> Contractor's !Name �� (cense Business Phone 3 a-7 <br /> Contractor's Address .& g:�- e -Rs.! Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 741 No <br /> TYPE OF WORK (CHECK): NEW WELL,- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX_ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy { <br /> Sewage Disposal Field i DLA ` Cesspool/Seepage Pit Other r <br /> t Property Line Private Domestic Well 4' *7A(Public`'Dor estic Well <br /> INTENDED USE TYPE OF WELL �--�- ----+ - <br /> ❑ INDUSTRIAL 9-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 /> ❑ G'EOPHYSICAI SurfaceSeal Installed By: a <br /> PUMP INSTALLATION: Contractor 7f4 -4-o - / -4 4.�"' <br /> Type of Pump sH:P: _ f <br /> PUMP, REPLACEMENT: s - ❑ State Work Done— --- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I he by certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinafices, 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 4 <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 /> ! will call,tor a-Gro -Ins pection_prtgr io_groufing_andaJinal_inspectian. <br /> Signed X � A� Title: --- _ Date: <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY F <br /> PHASE I <br /> Application Accepted B.- <br /> Date <br /> Additional Comments: -- <br /> Phase li Grout Inspection ase Ili Final Inspection <br /> Inspection By Date la`L9-96, Inspection By Date <br /> �JWh1Cd?UP.it;�1 Ldr So'�+� off Q�ov1L–,! y 6a®�,•�:�/red�.p.rr%'.v� ki�.ry z 4•.�/l�uca/ � . <br /> Fee Is Due: ❑ ANNUALLY !/❑ PER UNIT ❑ PER SfTF ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT ! <br /> _ ssf <br /> > FEE s <br /> $ LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> wi OTHER <br /> i OTHERly <br /> a 1 <br /> 1 -$ h 6 6S16 , n G7 Z 'Q so <br /> S Received by I Date Receipt No. Permit No. - Issu ce 15ate Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT15ERVICES -1601 E.HAZELTON.AVE.,P.O.Box 2009 - STOCKTON,CA 952101 F <br />