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Applications Will Be Processed When Submitted Properly Completed. Be r we7bS ntheApplication. <br /> FO OFFICE USE: VlJ r APPLICATIO�-5 ` ``��'� O�j +/ { <br /> - abbe I( 111J) ,(For Non Transferable, R . 5t�s <br /> '' PUMP&WELL � k <br /> aQnAENVIRONMENTAL LYH PERII�II �(��Q G <br /> (COMPLETE IN TRIPLICATE) WATER QU ]] �^ <br /> I Application is hereby made to the San Joaquin Local Health District fora permit to construct ak;t�brind/ort,Itska4ltt�aQ 'r� erein described.This application is <br /> made in compliance with San Joaquin Count Ordinance o. i8 2 and the rules ar � u �y�St)))o � oaquin Local Health District. <br /> Exact Site Address 2)_ �fty/Town ,may <br /> Owner's Name Phone { <br /> i Address City, 4' <br /> Contractor's Name _ License# �o � Business �5;�6 ZJ <br /> Contractor's Address � ��, r Emergency Phane <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 4 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Ir�� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I Sewage Disposal Field Cesspool/Seepage Pit Other <br /> F Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE _ TYPE dF,WELt_ <br /> ❑ INDUSTRIAL �- y❑�CABLE TOOL _ Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ' ❑ IRRIGAT..ION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION""^ "---,❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑'OTHER­—­:�-- Other InformationdT' <br /> f- I <br /> ` ❑ GEOPHYSICAL . S rface Seal-installed By: <br /> PUMP INSTALLATION: Contractor - i <br /> } Type of Pump 12r® - . . H.P. <br /> PUMP REPLACEMEIJ ❑ State Work Done <br /> 17 <br /> PUMP REPAIR: r ©mate Work Done f` <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 j <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 I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 <br /> r i call r a Grout Insp tion prior to routing and a final inspection. r <br /> Signed X Title: L� Date: 21 r <br /> k (Draw o an on Rever Side) _ <br /> FOR DE ARTMENT USE ONLY ! <br /> � PHASE <br /> t Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout-inspection P. se III'Ft I ect ' <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT M PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju1y 1 &Received By July 31 <br /> . BILLING REMITTANCE REMIT AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE f_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> ' PENALTY <br /> OTHER <br /> a OTHER <br /> Received by - Date Receipt No. _ Permit N6. Issuance Date Mailed Delivered ' <br /> APPLtCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />