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A" tions Will Be Processed W �il ubmitted PropenyGompleieu. oe AUFU IVAll �a^ • •4^rr••-- <br /> FOR OFFICE USE: APR 15 198 APPLICATION <br /> s-4 or Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> SAN JOAQUIN L(R- IRONMENTAL HEALTH PERMIT <br /> HEALTH DISTRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with Sa oaquin cgunty rdinace No.1862 and the rules and regulations of the San�1a uin o i_N It District. <br /> Exact Site Address ff .1111 �}.City/Town <br /> Owner's N SniTift Phone 7 <br /> AddressCity <br /> L f��PS License# Business Pho <br /> Contractor's Name Q� <br /> Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 3/ No <br /> IIKAI <br /> TYPE OF WORK (CHECK}: VIEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑/ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ N <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 <br /> ._, INTENDED USE TYPE OF WELL <br /> Y,i'NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> UJ DOMESTIC/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 /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done R <br /> PUMP REPAIR: ❑'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 g or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permi i s d, I shall em rsons subject to workman's compensa ' aws of California." <br /> I it out Ins ction for to grouting and a final inspectio . <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I y Lr is <br /> Application Accepted B <br /> r►r- -� Date <br /> Additional Comments. <br /> Phase II Grout Inspection hose III Final Inspection <br /> Inspection By Date Inspection By Date 1 rbc g <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 12f PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REWTTANCE $ AMOUNT DUE CHECKED , <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,C <br />