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Applications Will Be Processed When Submitted Properly Com td%RSu"To\,*The Application. <br /> FOR 27-ICE USE: APPLICAT );%/ <br /> (For Non-Transferable, uspendable <br /> A !q `' ��1 PUMP&WELL -� <br /> ENVIRONMENTAL LT H,�6 ()GPI. <br /> (COMPLETE IN TRIPLICATE) WATER Q Y t� `�1 -CC �G� <br /> Application is hereby made to the San Joaquin Local Health District fora permittoconstruct a ``l,,, Flee work herein described.This application is QQ <br /> made in compliance wit San Jooaaquin County r finance No 862 and the rules an� l�t�6(&f the San Joa uln Local Health District. <br /> Exact Site Address S / City/Town <br /> Owner's Name Phone 33 ?J <br /> Address City !� o <br /> Contractor's Name License G Z3 Business Phone <br /> Contractor's Address c Emergency Phone le C -51 -� <br /> Is Certificate of Workman's Compensation Insuran a 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 REPAIR P' <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 In tailed By: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ate Work Done k=xn_ns J <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ItE <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 c ora rout Inspe 'on prior to gro ting and a final inspection. <br /> Signed X Title: �lilJ Date: <br /> 7- ;1-7/? � <br /> aw Plot Plan on Revere Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date 1-719 <br /> Additional Comments: <br /> Phase II Grout Inspection Phasp.111 Final Inspection p <br /> Inspection By Date Inspection By Date 10-m-11— <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT/ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> :7 <br /> Received by Date Receipt No. Permit No. Issuance Dat4 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />