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Applications Will Be Processed When Submitted Properly Completed. Be SurerTo�g Ttieblloio .� <br /> FOR OFFICE USE: APPL:IGATION �' L( <br /> (For Non-Transferable, Revocable;Suspenda� ) PUMP&W <br /> r_ _ i <br /> ENVIRONMENTAL HEALTH PER {T'_' J A N " v 19$3 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . . .� . ._ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or inSciAll iJe.�fvhFk d�eretn des {r";_ This application is <br /> made in compliance with a�1 Cou rdina h1862 a rules I ns of t6dm L } <br /> p , � .. <br /> yrt� ith trict <br /> Exact Site Addres's/��,, Ity/Town <br /> Owner's Namv� F Phone_ � 4 <br /> Address �' City. <br /> Contractor's Name `� F "" J License./6, By,-jneess�Ph ne 46r`, <br /> Contractor's Address " d 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 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�n PP <br /> REPLACEMENT❑ Q.. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �t 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Weil Public Domestic Well <br /> INTENDED USE A.TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 415RILLED Dia. of Well Casing <br /> r ,❑,/DOMESTIC/PUBLIC <br /> U 1:1 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 /> ❑ GEOPHYSICAL Surface Seal Insta led BY:�� <br /> PUMP INSTALLATION: -Contracfdr� i <br /> Type of Pump H.P. �. <br /> PUMP REPLACEMENT ❑ State Work Done Q <br /> PUMP REPAIR: ✓ ❑ State Work Done <br /> DESTRUCTION OF WELL: WLel•1 Diameter Approximate•Depth f <br /> _-Describe Material and Procedure <br /> I hereby certify that I havie prepared this application and that the work wi11 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 <br /> is issued, I shall not employ any person in such manner as to become subject to orkman's compensation laws of California." <br /> Contractor's hi ' or sub-contrac 'ng signature certifies the following:"I cert' t in the performance of the work for which this <br /> per I shall employ perso s subject to workman's compensati n ws of California." <br /> I ill 1 o nspection rio o rou and a final inspeZe <br /> i <br /> Signed 7C` Title: ate: <br /> r (Draw Plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I t<< c <br />" Application Accepted BDate- - - <br /> Additional Comments. <br /> Phase 11 Grlb Inspection P e III Fina p CU <br /> Inspection By M 1 a Date Inspection By <br /> Fee IS DUe: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janua 1 eceived By January 31 July 1 Received By Ju 31 /�y <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMDUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i v <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ' F <br /> Received by - Date Receipt No. Permit No _ IsAuanc6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />