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.Applications Will Be Processed When Submitted Properly Com d.LWe?ur To Sign The Apb� 'tion. i <br /> FCiA OFFICE USE: APPLICATIO p �JJ <br /> (For Non-Transferable, Revocable, Suspendgay G 1979 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PgRM'JOAQUIN LOCAL ; <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH .DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with ,S.ttan Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address !- lY - p� , ! L ity%Town � J i <br /> Owner's Name , hone _ <br /> Address City <br /> Contractor's Name Wah tCt __� License# � Z_ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 9 <br /> r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ Ir l <br /> DISTANCE TO NEAREST: Septic TankSewer Lines /UO' Pit Privy 141 <br /> Sewage Disposal Fieyld 1 G Cesspool/Seepage Pit Other <br /> Property Line A Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t f l <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation !-! <br /> er <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing & <br /> DOMESTIC/PUBLIC ❑,DRIVEN Gauge of Casing � s� } <br /> ❑ IRRIGATION .GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ����"" t k <br /> ❑ DISPOSAL ( El OTHER Other Information J7 y .hum o— <br /> ❑ GEOPHYSICAL Surface Seal Installed By: (-n 4,/— <br /> PUMP <br /> ,/~PUMP INSTALLATION:. _,_ /Contractor <br /> .1,& <br /> , Ty <br /> pe of Pump H.P. <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure d <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 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 employ persons subject to workman's compensation laws of California." <br /> I will ca I for a Grout Inspection prior to grouting and a final inspection. <br /> G_ <br /> Signed X M t P1 tz Title: aeeld'!P J^ Date: � Z <br /> raw Plot Plan on Reverse Side) <br /> R DEP RTMENT7c, <br /> NLY <br /> PHASEI Q <br /> Application Accepted By Date �� c <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT. X PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATEON AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> � AMOUNT <br /> FEE - I.�7 <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt N0. Permit No, - I suance Date Mailed Delivered l�.�,/�, <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520' <br />