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I—+ Applications Will Be Processed When Submittecf"Properly Comp n eda$ILI <br /> u�@ Tri T Appllcafion. <br /> FOR OFF�fi E USE: APPLICAT ►( � lIj Eve UO <br /> (For Non-Transferable, Revoc Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HE PS"'76 1979 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to cons8Wngf).jNkJ1IJ*+MAtreindescribed.Thisapplicationis � <br /> made in compliance with San Joaquin CountOrdinance No. 1862 and the rules and rJ40AL0p+f� uin -c I Health District. <br /> Exact Site Address /0 L_�� City/Town <br /> Owner's Name e- Phone <br /> Address fd r City <br /> Contractor's Name License 4/4 Business Phone�� <br /> Contractor's Address Emergency Phone 4e'4 c ' 6 -XX__ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�� { <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other '! <br /> I F <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL' '` "NA.of'Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑-DRILLED Dia. of Well Casin gt <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal u <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout O <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL P Surface Seal-Installed By: <br /> PUMPINSTALLATION: Contractor F <br /> Type of Pump %F H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ F <br /> PUMP REPAIR: ®~State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <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 /> Homeowner 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 �Irut pection prior to uting and,a final inspection. <br /> Signed X Title: Date:' <br /> - <br /> -- <br /> raw Plot Plan on Bev..er a Side) <br /> FOR EPART ENT USE ONLY a <br /> PHASE 91-7 n F <br /> Application Accepted By Date l <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SkTE ❑NEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE. REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEj <br /> LESS / <br /> PRORATION <br /> - <br /> PLUS <br /> PENALTY <br /> w <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 5 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 <br /> i <br />