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Applications Will Be Processed When Submitted Pro erl pi i ul� 7o The Application. <br /> FOR OFFICE USE: APPL <br /> f (For Non-Transferable, cable,Suspcce��n�rdablleqe) o PUMP&WELL (�j1 <br /> ENVIRONMENTA AL`PigE�ftl'F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit tSANtrLian{tz)Tpr)Ss(_1h3iPork herein described.This application is <br /> Ji y✓ <br /> made in compliance with Cou na e No. 1862 and th rules b1� I�I tions of the San oa uln L I He th District. t <br /> Exact Site AddressR���✓ M City/Town <br /> Owner's Name Phone <br /> Address City Q <br /> Contractor's Name --- ' "7 "� License# Busin ss hone J <br /> Contractor's Address 'S Emergency Phone_ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRR�--' <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 <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 /> E] GEOPHYSICAL Surface Seal Installed By: ;1 <br /> PUMP INSTALLATION: Contractor CJ� <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: RState Work Done �O <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure �t <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." va <br /> Contractor's hirin r sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit I shall employ p ns subject to workman's compensat' laws of California." <br /> I I o Inspection rio to grouting and a final insp C- <br /> Signed X _ a£/h� Title: Date: <br /> (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ;�L/ /// <br /> Application Accepted By Date <br /> �S� a <br /> Additional Comments <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection ByN04 «i Date 3"-27—$O <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT OPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Dyd �5 <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 />