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Applications Will Be`'Processed When Submitted Properly Corrlq)MdrJd rj, Tgigth� lication. <br /> JOAOFFICE USE: APPLICATI 5 II '' 11 ��JJ ��}I <br /> (For Non-Transferable, Revoca I 1 u endable) <br /> ENVIRONMENTAL HEA U EIWIT 1 1980 PUMP&WELL <br /> WATER QUALITY �O <br /> (COMPLETE IN TRIPLICATE) Q ft i ^} ;` t,A <br /> Application is hereby made to the San Joaquin Local Health District for ermittoconstruc otjiostL�# ye ol;in <br /> r in described.This application is <br /> made in compliance with San J9 u Co O ina o. 1 the rules and regul�i�r 0oo�tne))arpdo L ith Istrict. <br /> Exact Site Address Q City/Town �' <br /> Owner's Name `-'l7' 4, Phone <br /> Phone <br /> Address �� City �- <br /> .-- O� <br /> Contractor's Name 457'�-� �2 C-fA4 � License# �3/�3 BusineTss/Pl;yon,�, ��, � <br /> Contractor's Address Emergency Phone A114-6 GG `�!! <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 REPAIRL�J' <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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: B'State Work Don ' <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 -contractin signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is ' ued, all employ rson subject to workman's compensation s of California." <br /> I will II f r pectin or uting,.p,nd a final inspect' <br /> Signed X Title: Date: f <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By 1, ` ""` �i Date <br /> Additional Comments: y <br /> Phas I Grout Inspection Phase III Final Inspection ^7 O <br /> Inspection By Date Inspection By tt Date I '- /�O <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER <br /> OTHER ( %� <br /> l CJ <br /> Received by Date Receipt No. Permit No. Nsuanc6 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 />