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Applications Will Be Processed When Submitted Properly Coad 17""rf?T4ggi T Application. <br /> FOR OFFICE USE: APPLICATI I i �y �{? <br /> For Non-Transferable Revoc ' us e dable _4 � I .w <br /> . ( � �,� P ) P&WELL 1 / <br /> ENVIRONMENTAL HEALTH PEP4JT4 ,s 'j%id; <br /> {COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconst WWn kt,"1 Metl@r eindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and r4gl(EAWROf E JQi4uin Local Health District. <br /> Exact Site Address S >X020 z City/Town rC <br /> Owner's Names =� x� Phone <br /> Address C �'�� - _ City— <br /> Contractor's <br /> ity Contractor's Name License# Business Phone ��/ `I/�2 <br /> Contractor's Address j �� ; ti� 7 Emergency Phone V <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION C) DESTRUCTION Q O <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11' 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 /> 02/1-N'DUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing, " <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <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 PumpL24, <br /> �� H.P. <br /> PUMP REPLACEMENT: 0 State Work Done�? d, 4uz�4, > <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 fora Grout Inspection prior to grouting and a final inspection. <br /> /7 �,^ <br /> Signed X J 11 .� /t ov ^ ( ��zw Title: ars <br /> � � � ��_�,Z Date: ( � <br /> (Draw Piot Plan on Reverse Side)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III nspection Jr <br /> Inspection By_- Date Inspection By �i 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 /> B�LLING REMITTANCJ= $ <br /> BASE EXPLANATION 'DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> 00 <br /> �5 <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. JissuinCe 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 />