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{ plicationsWill Be ProcessedL%Vh,6n Submitted Properly Completed. Be Sure,To Sign The Application. <br /> FOR OFME USE: JUN 2 1980 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> SAN .1OAQ IN Lor+ VIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> HEAUTH_IDISTMCT QUALITY � ll O <br /> (COMPLETE IN TRIPLICATE) tt bO ( 'AJ.. C��fTER �l` �OR�C�74�I 9. <br /> Application is hereby made to the San hJoaquin Local Health District fora permit to construct and/or install the work herein described.This application Js <br /> made in compliance with San Joaquin County Ordinance o. 1862 a Y the rulgs and g lations of the San Joaquin Local Heal # <br /> District. a <br /> Exact Site Address �� p,e4'1� _)dr e Z City/Town �' <br /> Owner's Name �" d �IV Phone 4-77 O 7 <br /> Address E)"7 /gIr 9of—r City J 7-16 C <br /> Contractor's Name L License Bus�ihess Phone '`F <br /> Contractor's Address ` 1 Emergency Phone (« ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW�WELL❑ DEEPEN ❑ RECONDITION El DESTRUCTION❑ d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM t <br /> REPLACEMENT❑ I t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0-DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal y <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ra <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. LT <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Don- -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depthg_o <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. d <br /> Home owner or licensed agent's signature certifies the following:".I certify that in the performance of the work forwhich this permit k -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' g or sub-contracting signature certifies the foilowingi"I fy that in the performance of the work for which this <br /> pe <br /> g1sued, I all empI per ons subject to workman's compe a ' n laws of California." <br /> will t Inslpec ion pr to grouting and a final inspec I / <br /> Signed X I .Title: ~~,•✓ Date: , <br /> I� (Draw Plot Plan on Reverse Side) <br /> . � I <br /> OR USE ONLY ' <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: �hhh� _ - - <br /> Phase�II Grout Inspection Phase III Final Inspection <br /> Inspection By �� Date Inspection By Date M <br /> Fee Is Due: ❑ ANNUALLY I❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> } BILLING REMITTANCE $ REMIT. 'r <br /> BASE EXPLANATION AMOUNTMDUE CHECKED . <br /> - DATE DATE REMITTED - AMOUNT <br /> FEE v <br /> LESS ✓f' <br /> PRORATIONIN, - <br /> PLUS <br /> PENALTY II - <br /> OTHER I <br /> OTHERII <br /> Received by Date I` Receipt No. Permit No. Issuance Date Mailed Delivered 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P:0.Box 2009 STOCKTON,CA 95201 <br /> !k _ w <br />