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- T Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> (rpt ENVIRONMENTAL HEALTH PERMIT. <br /> QUALITY /3 f <br /> (COMPLETE IN TRIPLICATE) ',C�(r3-0-t✓11.•- �{[ rre/rQ _ x A�, €t ' <br /> Application is hereby made to the San Joaquin Local 'Ith Districtfb_r permit to construct and/or install the work.herein described.This application is <br /> made incompliance with.San.Joaquin Countyrdinan a No. 1862 and the rules and regulations of the San Joaquin Local Health District. y <br /> Exact Site Address f&dY1�� `p��' "4`�a' � City/Town x <br /> Phone <br /> Owner's Name <br /> s. City.— _ <br /> Address <br /> - License# -• Business Phone .•14.G Il.; <br /> Contractor's Name <br /> e r <br /> Contractor's Address Emergency Phone <br /> ...- <br /> Is Certificate of Workman's Compensation Ins n on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑' " DESTRUCTION❑ r <br /> l 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 z Cesspool/Seepage Pit Other <br /> t Property Line Private Domestic Well -Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation99 - <br /> ❑ DRILLED g Dia. of Well Casing <br /> DOMESTIC/PRIVATE � - - - -v <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK - Depth of-Grout Seal --Cr <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 1:1 GEOPHYSICAL g Surface Seal Installed Bi <br /> PUMP INSTALLATION: Contractor ,� f t a j <br /> r 7Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> [I State Work Done <br /> Approximate Depth <br /> 13State Work Done i <br /> " <br /> DESTRUCTION OF WELL: r x ,:,Well Diameter <br /> PUMP REPAIR: z <br /> Describe Material and Procedure I �. <br /> I hereby certify that I fiaveAprepared 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 forwhich this <br /> permit is issued, I shall 4nploy persons subject tp workman's compensation laws of California." <br /> I will call fora Grout Inspectio Yp r gr d Ing d a f n I inspection.- <br /> " Signed X tom• Dale:. <br /> (Draw Plot PI on Reverse Side) , , <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I - req Date f2_ / <br /> Application Accepted By <br /> t <br /> Additional Comments: _ - <br /> Phase II Grout Inspection - ` P a III Fin I Inspection �{� <br /> # pate WA- Inspection By v"K Date �2�/ 4/ <br /> Inspection By - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT F <br /> il •BILLING _REMITTANCE $ - AMOUNT DUE CHECKED - <br /> BASE EXPLANATION <br /> DATE DATE REMITTED. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS F _ <br /> PENALTY <br /> OTHER k <br /> is <br /> OTHER <br /> .. Received 6y Date - - .'Receipt No.' Permit No, � .15su nce Dat � I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Bax 2409 STOCKTON,CA 95201 <br />