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Applications Will Be Processed When Submitted Properly Complet a Sure To Sign The Applic t o <br /> FOR OFFICE USE: APPLICATION G 1980 <br /> ' (For Non-Transferable, Revocable, Suspendable <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIN J )A 1UIV LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DIST ICT <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wrt an Joaqv�Co Ordinanc No: 1862 and the rules'and regulations gSan Jn Local-hHealth District. <br /> Exact Site Address ] _ ` L ham) —/v4�rQky/4 !' <br /> Owner's Name _ � 61k. , Phone <br /> Address +� <br /> city �_�ca*,, <br /> Contractor's Name License# Mt-Business Phoneme <br /> ContractorYP it s � �* �,�__ i Emergency Phone 777 - 171 V 777 � <br /> Is Certificate of Workman's Compensation Insujra�e on File With SJLHD? Yes _ No VA <br /> TYPE OF WORK (CHECK): NEW WELL B DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q--' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /'bey Sewer Lines/6Z� 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 <br /> ❑,�, IN STRIAL ❑ CABLE TOOL Dia. of Well Excavation��+ <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Ql <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IGATION ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION OIROTARY Type of Grout 4 :}.+ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL__ Surface Seal Installed By: <br /> PUMP INSTALLATION: '� <br /> Contractor rs ekst ,E: <br /> Type of Pump � H.P. Z <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X (I)MI—_ DE�L�I � Title: C„?( -- Dat <br /> (Draw Plot Plan on Reverse Side) <br /> OR PARTME T USE ONLY <br /> PHASE <br /> Application Accepted By 8 <br /> Date <br /> Additional Comments: al� o <br /> ha II Grout Inspection > haselwt. final Inspection <br /> Inspection By �,� Date b. <br /> l Inspection By 'Date <br /> _ e ,,. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> { DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s o SSG z z <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />