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Bepr6cbs hen Submitted Properly Completed. Be Sure To Sign The Application. �— <br /> FOR OFFICE USI APPLICATION <br /> JU L 10 1980 (For Non-Transferable, Revocable,Suspendable) � S <br /> dA-,y y" PUMP&WELL <br /> N JCJ�IQUlN l6��AFLIlIVIRONMENTAL HEALTH PERMIT µ <br /> (COMPLETE IN TRIPLIC WATER QUALITY ��_ -3s <br /> IrALH DlSTRlCT <br /> Application is hereby it etothe anJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance/ ith S�1 Joa uin County Or finance No. 1852 andhe�ules angu tions of the San Joa i al Health Di trict. <br /> -Exact Site Address- �a .� 07;.11 <br /> — -�—� City/Town �w <br /> Owner's Name Qa t— Phone <br /> Address City <br /> Contractor's Name .LlYI Q, � License Business Phone <br /> Contractor's Address l <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ + <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - OTHER ❑ �S PUMP INSTALLATION ❑ PUMP REPAIR ElREPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other f <br />! Property Line Private Domestic Well Public Domestic Well I <br /> i <br /> INTENDED USE TYPE OF WELL 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ tate Work Done t^, <br /> PUMP REPAIR: I!� State Work Done PJ <br /> Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T y 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 forwhich 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 ;l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> Zfor Grout Insp n prior grouti and a final inspection. <br /> Signed X �n <br /> Title: Date: (Jc� <br /> (Draw Plot Plan on Rev a Side) <br /> FOR D ART ENT USE ONLY <br /> PHASE t <br /> Application Accepted By Date U <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 7 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT 11 <br /> DAT DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT I <br /> FEE <br /> LESS - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. ! suan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCI(TON,CA 95201 <br />