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Applications Will Be Procesggd,NJlen Submitted Properly Completed. Be SureToSignTrieAPP:ication. <br /> FOR OFFICE USE: l APPLICATION 11 <br /> (For Non-Transferable, Revocable,,�uspendable) I <br /> PUMP&WELL W <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE.IN-TRIPLICATE) WATER QUALITY <br /> Application is hereby made,to the San Joaquin Local Health Districtfora permit to construct and/or instal cation is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and"regulations of tI <br /> Exact Site Address_cc 3 4A#1a1 A/, �' cQt City/To <br /> Owner's Name .tsr�2 u 4�[ bu Y _. Phone i <br /> Address Y .v City_ <br /> Contractor's Name rt License# /f_?=Busine <br /> Contractor's Address ao 2-iiil JF Emergency Phone <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes o <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 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 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL F i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation-- <br /> 0 <br /> xcavation❑ 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 ,5�e u1�a✓ Other Information AA?-I & r-0- <br /> ❑ GEOPHYSICAL -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump re H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 18 State Work Done r <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 /> Home owner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> F <br /> I will call for a Grout Inspecti r' r uting and a final inspection. <br /> Signed X, Title: _., &4z Date: <br /> (Draw Plo Plan on Reverse Side) <br /> FOR EPART NT USE ONLY <br /> PHASE I / <br /> Application Accepted By ` di Date1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phi Aig <br /> nalpection ��,�j <br /> Inspection By Date Inspection By Date ��R <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received 8 y 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE le <br /> LESS <br /> PRORATION pPLUS w V <br /> PENALTY v ' <br /> OTHER <br /> OTHER <br /> v—I9-13y3 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />