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Applications Will Be_P-rocesSBd When Submitted Properly CompleteSure To Sign The Applica gV <br /> APPLICATION 0 <br /> F FOR OFFICE USE: � �'- '� AUG�'{�� ,t� � <br /> i •est„„-. i _ (For Non-Transferable,Revocable,Suspendable) <br /> P&WELL <br /> .r= ENVIRONMENTAL HEALTH PERWAN JOAQUIN LO�`��` <br /> I (COMPLETE IN TRIPLICATE) " WATER QUALITY <br /> HEALTH DISTRICT <br /> Application is hereby made tothe San J�ju L Meal Di trictfora r it to construct and/oriristallthework herein described.This application is <br /> made in compliance wi h San Joaquin C4etlr �anc n -e les and regulations of the San JWquin cat Health District. <br /> ' Exact Site Address T,6 (� City/Town <�Ic- -% <br /> Owner's Name Phone <br /> Address 1 Cityr �—.� <br /> Contractor's Name License3Business Phone ! <br /> Contractor's Add Emergency Phone <br /> Is Certificate of Workman's Compensation Innsurran�on File With SJ LH D? Yes 4--_ No <br /> TYPE OF WORK (CHECK): NEW WELL 0— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> # DISTANCE TO NEAREST: Septic Tank Sewer Lines /LJ Pit Privy -71 <br /> Sewage Disposal Field rt Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL a rF <br /> i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> Vk <br /> k ❑ D MESTIC/PUBLIC 13DRIVEN Gauge of Casing IF <br /> t <br /> I1i�IRR1GATION C1 GRAVEL PACK Depth of Grout Seal AZO / KR i st a /i el" <br /> �� <br /> ❑ CATHODIC PROTECTION 1�"7iOTARY Type of Grout <br /> F ❑ DISPOSAL i ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �� <br /> M Type of Pump_7ta 0% 19 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I; ❑ State Work Done r� <br /> DESTRUCTION OF WELL: r Well Diameter- Approximate Depth <br /> Describe Material and-Procedure <br /> I 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 /> Hofne 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will <br /> call <br /> �for a Inspection nspection prior to grouting and a final inspection. <br /> Signed X L ?+ -- 'Title: , P " Dater <br /> Ck <br /> (Draw Plot Plan on Reverse Side) <br /> R D ARTME USE ONLY <br /> �i <br /> PHASE I <br /> Application Accepted By 1} 0� _ Date <br /> Additional Comments: <br /> d �` ,► <br /> [[ Phase 11 Grout Inspection P ase lil F'nal Inspection <br /> I. Inspection By Dated -..._ Inspection By Date !--7-f-3 <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> " <br /> BASE Ex PLANATION - BILLING REMITTANCE $ AMOUNT DUES CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION h <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> :rho Y6�z �7�iQv s=fi0 <br /> Received by - Daie Receipt No. Permit No, Issuance Date Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />