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]cations Will Be Processed Submitted Properly Completed. BeSure � <br /> FOR OFFICE USE: DEC 2 111982 APPLICATION i� <br /> {For Non-Transierable, Revocable, Suspendable) PUMP &WELL <br /> SAN JOAQUIN L09ft IRON MENTAL HEALTH PERMIT <br /> H 015-FRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICA <br /> AMT <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou ty Ordinance No. 1862 and the rules and regulations of the San qujin Local Health District. i <br /> Exact Site Address �?� r CP.Y"YC7L{ � City/Town P01^ + <br /> Owner's Name .�v�� <br /> Phone <br /> t <br /> S'- f�G�Y V Ile, - City p`^ <br /> Address _ 7 (p <br /> Contractor's Name Wr'► <br /> License# �r��Business Phone <br /> t v-L Emergency Phone <br /> Contractor's Address l� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4K:,_ No <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ OO�Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR© <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage <br /> 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 /> 11 DRILLED Dia- of Well Casing ` <br /> ❑ DOMESTIC/PRIVATE � <br /> 111❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3 <br /> I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> LJ CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 4 Other Information <br /> 13 GEOPHYSICAL SurfNe Seal Inst Iled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done tlf <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 /> a Home owner 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 /> 1coli for a Grout Inspect n prior to grouting and a final ins jwLll, n. f� 'G '+ <br /> , Title: f'P� m Date: �h <br /> { Signed X ._ — <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I 0__ OK/ — Date _Z_3 <br /> Application Accepted By <br /> f Additional Comments: <br /> �G.roui Inspection P s 111 Final Inspection <br /> h n <br /> Inspection By Date Inspection By Date <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July s 8 ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED e AMOUNT <br /> t, FEE <br /> [ LESS <br /> I PRORATION <br /> PLUS <br /> i PENALTY _ <br /> OTHER <br /> OTHER <br /> Issuance Dat Mailed Delivered <br /> Received by <br /> Date Receipt No. -Permit No. — ._. <br /> a 20 <br /> 11 <br /> L HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Sar 2009 -STOCKTON,CA 95 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAp <br />