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q <br /> Ap Be Procs�>�`�j(hen Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: $ G9 tAPPLICATION <br /> (FQr f(Jmnsferable,Revocable,Suspendable) PUMP&WELL <br /> 1^ �ANMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) L l <br /> {i WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal I the work herein described.This application is <br /> made in compliance with ScV Joaqu. County Ordinance1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 17Y +i� Q�-�6"� �c�� City/Town Z5_4F92_ <br /> Owner's Name Phone 2-3-9-/57/ <br /> l <br /> Address 2 l r���� City <br /> Contractor's Name m `L <br /> /�#� � •: - License#` ()P& Business Phone 237 <br /> Contractor's Address 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 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Q6 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 6'�'�1��c'X "' " <br /> Type of Pump J,�� H.P. (� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> M State Work Done V <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 /> Home owner 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 allforut Inspection prior to grouting and a final Inspection. <br /> Signed X Title: Date: ��2 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI It A <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph se ILI Final lnspection� / �� <br /> Inspection By Date_ Inspection By ate <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 /> PRORATION <br /> PLUS �C f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate Receipt N Permit No. Issu nce 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 />