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r <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL J�J <br /> ENVIRONMENTAL HEALTH-PERMIT �/ <br /> COMPLETE IN TRIPLICATE r�, 3?,3 x d, t7y4 vrs" QUALITY , ,,� fps-.23 D-CS^ <br /> ( ) -WATER at <br /> Application is hereby made to the San Joaquin Local Health District fora per.rnit to construct and/or Install the work herein described.This application is <br /> made in compliance with San Joaquin County.Ordinance No. 1862 and the rules and regulations of the'San Joaquin L cal Health District. <br /> Exact Site Address k ! J#L sP City/Town <br /> Owner's'Name Mid u1nic- =F`iE+ `� 4 Phone} <br /> Address /4 1rl7� _ City1.A' .rr <br /> Contractor's Nam a License# 4 fA' .Business Phone a � <br /> Contractor's Address 7 " " Emerdency Phone <br /> i Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes _ -_ No <br /> TYPE OF WORK (CHECK): " NEW WELL❑' - DEEPEN R EGON DtT-1-04❑ DESTRUCTION❑`.- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ -._PUMP. INSTALLATION ❑ PUMP-REPAIR. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lees Pit Privy <br /> Sewage Disposal Field - .Cesspool/Seepage Pit Other - <br /> Property Line Private DomesticWell Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation it <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC Y ❑ DRIVEN Gauge of Casing N <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> i ❑ DISPOSALL ❑ OTHER Other Informatioi <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor<S4Ii L1.1 <br /> Type of Pump Ek H.P. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done . t <br /> PUMP REPAIR: �State Work'Done /8/ 0— <br /> DESTRUCTION OF WELL: Well Diameter ) Approximate Depth <br /> I Describe Material and Procedure ._ <br /> 2 <br /> I I hereby certify that I have prepared this application and that the Work will be done iri 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 work riian's compensation laws of California"', <br /> Contractor's hiring or sub-conlracting signature ceitifies 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." a <br /> _Lvf II call for a Grout Insp to br gr ng an final inspection. _ _ R •. <br /> Signed .` Hle: n�� k Date: /f" <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE'I Q f <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Phase li Grout Inspection Phas III Final Inspection <br /> Inspection By -= -Date� T `- Inspection Date ` e J <br /> ' Fee IS Due: ❑ ANNUACL��❑,PER UNITY' ❑ PER SITE ❑£ACHE"" ❑ January 1 a.Received By January 31 ❑•Jufiq 1 &Received By Jury 31 ' <br /> t - - y REMIT <br /> BASE, EXPLANATION <br /> BILLING v REMITTANCE r $ <br /> AMOUNT DUE CHECKED <br /> r { -^!� r,D'ATE1 JJ DATE. f REMITTED AMOUNT <br /> S FEE ��� �X I LVC�'+ ,! :r F <br /> LESS . #.. ,r q <br /> PRORATION x <br /> PLUS --q <br /> PENALTY <br /> OTHER <br /> r F <br /> r <br /> OTHER <br /> Received by Date- o _ Receipt No. PLSrmit No. Asivance Date Maned-- Delivered „ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />