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Applications Will Be Processed When Submitted Properly Comple,,e teutejTa` ig Application. <br /> uj <br /> FOR OFFICE USE: r APPLICQT E � 4 V ! <br /> (For Non-Transferablg, Re le ' s�iendable) <br /> ENVIRONMENTAL H H P�F�F�nnW 1q�o PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t ol,'At <br /> Application is hereby made to the San Joaquin Local Health District fora permittoconstruc nWn <br /> 4Qf'lltla tc'kereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and tt �F URan Joaquin Local Health District. <br /> Exact Site Address 335S ! /LJ ►�11 City/Town C�,✓ G— <br /> Owner's Name Phone <br /> Address Z 3 S S aa', ��1 Cityr <br /> Contractor's Name License# fir%,2 3?3 Business Phone <br /> Contractor's Address Emergency Phoned S4.�2S <br /> Is Certificate of Workman's Compensati n Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 6� <br /> WELL CHLORINAPON ❑ 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 <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 4,a <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r 7 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 111 <br /> Typo of Pump /� H.P._ �z <br /> PUMP REPLACEMENT: State Work Done {e!/ll �� ��� , /�� a�/ W v <br /> PUMP REPAIR: ❑ State Work Done tf C <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 forwhich this <br /> OeTmit is issued,.,) shall employ persons subject to workman's compensation laws of California." <br /> � <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> /` <br /> Signed X ,e.ti --h. g 1 Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPART NT USE ONLY <br /> PHASE <br /> Application Accepted By x A ,AlDate <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 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 <br /> LESS <br /> t PRORATION <br /> PLUS / f //,b <br /> PENALTY �f! <br /> OTHER (y✓Jlii•t �(� <br /> O 1..Jr vY C✓ � GEi <br /> OTHER <br /> C5`m90 - - o <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 />