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"r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR OFFICE USE: /_0 <br /> � <br /> (For Non-Transferable, Revocable, Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP WELL <br /> & J <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY G <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Oidinance No. 1862 9nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address A33&3 G4Rrzj L'2 DAY A-e. _ City/Town T�C-y i <br /> 92-1 <br /> ; <br /> Owner's Name A:7-,;D. ..yliLC S I PhonB3� & <br /> Address .12��_ City <br /> Contractor's Name IFP4=A _S AEk�o_— 1 License 4-33947/ Business Phone S �& 4 <br /> Contractor's AddressRL?r //�,5 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION A PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <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 f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ,KDOMESTIC/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 /> ❑ GEOPHYSICAL Surface Seal In�talled By: <br /> PUMP INSTALLATION: Contractor _ <br /> = Type of Pump er H.P. ON IG <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: i ❑ State Work Done <br /> DESTRUGTION.OF WELL: i Well Diameter Approximate Depth <br /> T Describe Material and Procedure <br /> ✓ l ,sem .. .... <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, stateilaw' s, and rules and regulations of the San Joaquin Local Health District. <br /> j <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 workman's compensation laws of California.'; j <br /> Contractor's hiring or sub-contractlriig°signat6e certifies the following'E1Tcertify that in the performance of the work for which this. <br /> permit is issued, I shall employ persons subject_to workman:s-compensation-laws-of-Calif ornia.-" <br /> I wi I or a GroutInspection prior to grouting and a final inspection. bra <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 4 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By � Date <br /> Additional Comments: i <br /> Phase II Grout Inspection Please II Firta I spection <br /> Inspection By 1 Date Inspection By Date <br /> 1 <br /> Fee IS Due: ❑ ANNUALLY I ❑ PER UNIT PER SITEEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BASSIBILLING REMITTANCE $. EXPLANATION AMOUNT pUE CHECKED <br /> DATE DATE REMITTED <br /> F AMOUNT <br /> FEE <br /> LESS <br /> PRORATION S <br /> PLUS <br /> PENALTY <br /> b <br /> OTHER <br /> OTHER <br /> 7 F <br /> Received by Date Receipt No. Permit Issuance Date Mailed Delry ed } <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTALHEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 1 <br />