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- Applications Will'Be Processed When Submitted Properly Completed. Be Sure To Sign Xbr,,Application. <br /> 'FOR OFFICE USE: - APPLICATION , <br /> k _ (For Non-Transferable, Revocable, c 1L V I <br /> � 41 t VVV PUMP&WELD. <br /> ENVIRONMENTAL HEALT114 tE IT <br /> i y J p, 1ga1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALI <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install t�htew rtMku1 described.This application is <br /> made in compliance with San/Joaquin Qounty Ordinance No. 1862 and the rules and regulati0 a�c� Bar �n Local Health District. 4 <br /> Exact Site Address / 7e _,de=e d,40 WA&b,� � !E��#yrtT�wpks _ <br /> tr L p <br /> Owner's Name h Phone d 3 S- S/�-�' <br /> Address I?,/— City ' <br /> Contractor's Name .t TLicense# Business Phone _:'s <br /> Contractor's Address /�fJ' �+ /�� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 4 I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L7 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE s r TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> IVOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing f <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H.P, i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter P` `S `'_'ti* frAkfti4ffh <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 /> Home owner or,licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit _J <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 /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X )C 6,41, 227 (6/ tr ^ry —' m �,�1iu.s —'Title: Date: <br /> A (Draw Plot Plan on Reverse Side <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ate yr� f <br /> Additional Comments: <br /> Phase 11 Grout Inspection ,Phase III Final- s 5tio <br /> Inspection By Date Inspection <br /> Fee IS Due: 11ANNUALLY ❑ PER UNIT C1PER SITE ❑ EACH ❑ January 1 &Received By J ny 3, LJ Jul(t a R ceived By July 37 <br /> REMIT <br /> BILLING REMITTANCE $ /Jir <br /> BASE EXPLANATION DATE DATE REMITTE[7 ''MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> f PENALTY _ m <br /> I OTHER <br /> OTHER <br /> Pk <br /> Received by - Date Receipt No. - y Permit No. Issuance'Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES E.HAZELTON,AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />