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Alwic sWill Be Processed Wb ubmltted Properly Completed. Be Sure To.Sign The Application. <br /> FOR.(�FFFCtiff <br /> f USE: R 2 � $0 AOPLICATICN <br /> . `' v � (For Non-Transferable, Revocable,Suspendable) <br /> 3 PUMP&WELL <br /> SASS 'Olj!N V NMENTAL HEALTH PERMIT <br /> i- (COMPLETE IN TRIPLICATE) HEALTH DiS WATER QUALITY <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 /> r <br /> made in compliance with San Joaquin County O I#inance No. 1862 and the rules and regulations Of the Sa Joaquin Local Health District.A94 An- <br /> - <br /> Exact Site Address C' y/Town 1V 11111T <br /> " l - I hone <br /> Owner's Name .. . . <br /> F. Address c 3 ` City �3 0 <br /> Contractor's Name �-'� License# E` Business Phone _` <br /> j Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I>e— No <br /> TYPE OF WORK (CHECK): NEW WELL 54' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Wx PUMP REPAIR❑ S <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank NP r— Sewer Lines IN V t,&. - Pit Privy <br /> #t ; Sewage Disposal Field�no Lif— Cesspool/Seepage Pit Other �l <br /> { Y. <br /> Property LineE Private Domestic Well Public Domestic Well hDntt� <br /> INTENDED USE `= TYPE OF WELL <br /> 0 INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing -F'j r <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing / <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ( ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout q r <br /> El, DISPOSAL ❑ OTHER Other Information 11 w <br /> M CJ <br /> GEOPHYSICAL--,—, Surfaceal Installed By: `f, ��c�'c�- X71nJJ r� <br /> RUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ Staa Work Done <br /> PUMP REPAIR: + x ❑ State Work Done <br /> -� —A roximateDepth <br /> DESTRUCTION OF WELL: Well Diameter ! Approximate <br /> Describe Material and Procedure_ <br /> t <br /> t4_ 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 /> r~r <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 forwhich this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I will all for a Grout Inspection prior to grouting and a final inspection. ^ <br /> Signed X T Title: ' I/«�.L�3111-1� Date: <br /> a d(Draw Plot Plan on Reverse Side) <br /> ` /FODEPA MENT USE ONLY <br /> PHASE IApplication Accepted By Date <br /> Additional Comments: f�11P Gout Inspection J <br /> �P 41FInspection <br /> Inspection By <br /> Date l <br /> Inspection By � <br /> � K <br /> t k � <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UN/ ER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuVy 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> i. . <br /> FEE . " T , ■ t t_ <br /> 43 <br /> LESS - <br /> PRORATION <br /> - PLUS �'.'... _. .;.xp. -�..- .. ., + .:-,r.,w...4.. .r' r.. -•... ti.. •w.. -..,,..�,r -. s . +•. <br /> 4 PENALTY <br /> F ` OTHER •* -t - - - <br /> [t! f- OTHER " <br /> -15 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL,HEALTH'PEpMIT/SERVICES ;. . 1601 E.HAZELTON AVE.,P.O.Boil 2009 STOCKTON,CA 95201 <br />