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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The t%atin. 1111 <br /> ` <br /> FOR OFFICE USE: APPLICATION �� FEB 221983 <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAH JOAQUIIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUAUT1f LAS.t}� II T <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J uin County Ordinance862 and the rules and regulations of the San Joaquin L cal_Health District. <br /> Exact Site Address—t3-A- � A A City/Town L� M/9 1`'' <br /> Owner's Name �J Phone <br /> - <br /> Address ` 14 ✓ G IVA City tf�_C# 7 <br /> Contractor's Name 1 ,- g 5 b," License#,MOID Business Phone <br /> Contractor's Address o2 C`03 EmergencyPhon fv/4'�' +v <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 IN <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 (Y <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: IN State Work Done V 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 cal for a ou spection prior to grouting and a final inspection. <br /> r <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTME SE ONLY <br /> PHASEI <br /> Application Accepted By Date���� <br /> Additional Comment . <br /> h I Grout Inspection h sill Final Inspection <br /> Inspection By Date Inspection By Dates <br /> Fee Is Due: ❑ ANNUALI ❑ 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No. Is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO., ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />