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Ww <br /> I r II Be Processed�n Submitted Properly Completed. BeSureToSignTheAppncaiton. r <br /> FOR OFFICE USE: 19�2 APPLICATION <br /> PUMP&WELL <br /> SEC (For qqn-Transferable,Revocable,Suspendable) <br /> ;}i1.s0NMENTAL H_A0 PERMIT <br /> 04 WATER QUALITY;;"-,.:,�.� <br /> (COMPLETE IN TRIPLICATE? a>*' <br /> Application is hereby made totheJoaquinLocalHealthDistrictforap <br /> � ermit to construct and/or install the work herein described.Th is application is <br /> made in compliance with San Joaquin CoLi y O 'nance No.,1B nd e.rules and^regulatio. of the San Joaq ocal H alth istrict. I <br /> Exact Site Address <br /> r I:J j City/Town . <br /> t �i� '� n„�.—�,.. .,� '�„: �t'^���rxoII1 L-L�- - ,• r �'"s�_ - Phoned 65?�_} <br /> 7/' <br /> Owner's Name City r <br /> Address a <br /> �; ff' "� ,v *u License#o21” t01 Z) Business Phone r <br /> ' Contractor's Name r" r <br /> Contractor's Address 2^03 Emergency Phoris -i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK'(CHECK):_ NEW WELL❑_M DEEPEN❑ RECONDITION❑ DESTRUCTION❑ ~ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT 19. - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well a <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL" ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED <br /> Dia. of Well Casing <br /> I�. � DOMESTIC/PRIVATE - - " <br /> D,DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal F <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ElOTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work done 't <br /> PUMP REPAIR: ❑ State Work Done <br /> � Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <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 /> f 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 to "I certify that in the performance of the work forwhich this , <br /> permit is issued, I 11 emp oy persons subject to workman's compensation I ws of Caleifornia." <br /> I wi c 'Ili a Gr ut ns' lion prior to grouting and a final inspec j. <br /> Signed X z" Title: Date: <br /> �o A <br /> k (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ©/ -1�' - <br /> PHASE O <br /> Date <br /> Application Accepted By <br /> r 2 <br /> Additional Comments: _ <br /> Phase II Grout Inspectionh ae 1 Final Inspection <br /> n 1 n .,"-•• =" Date Inspection By Date <br /> Inspection By i <br /> Fee Is Due: El ANNUALLY r ❑ PER UNIT k❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 8 Received <br /> REMIT <br /> uly 31 <br /> BASE 'EXPLANATION BILLING REMITTANCE.: - $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS " <br /> PRORATION { _ - <br /> PLOS <br /> PENALTY <br /> OTHER <br /> OTHER~ <br /> Received by <br /> Dat - - - Receipt No. - Permit No "Issuance Date - Mailed.-- Delivered <br /> STOCKTON,CA 95207 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT <br /> laERVICEa 1601 E.HAZELTON AVE.,P.O.SON 2009 <br />