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Apo atl�inCWil(„Be Pr6R6s$_*d When,Submitted Properly Completed. Se Sure To Sign The Application. <br /> . F.JfI OFFICE USE: J a . 1 V Ji APPLICATION <br /> (For 1h, transferable, Revocable,Suspendable) PUMP&WELL <br /> -A I J�2ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY, <br /> (COMPLETE-IN TRIPLICA Ill l 1 r � ,.. , O# <br /> Application is hereby madetC�}}tf�f� .SarrlJo�tqulteLo_atlta District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with Sart'JiGti�t Clot#rfyaC]ri�al�ce No. 1862 and the rules and regulations of theSanJoaquin Local Health District. <br /> Exact Site Address City/Town <br /> I Owner's Name s '°:�%o�' Phone S%- M75 <br /> Address il 5 9 t u1 ;:. i city”, . <br /> Contractor's Name .� " .g,3 License#_/6-.2 37 Business Phone <br /> Contractor's Address M r' /9 7;.: _ �j -� al Emergency Phone. �4r. ,_ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): _ NEW WELL❑ DEEPENI❑ RECON'D'ITION-El ^DESTRUCTIO,.N,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION Lo PUMP REPAIR❑ T -- <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 /> E ❑ DUSTRIAL ❑ CABLE TOOL ''°D.ia:'af Well Excavation- - <br /> ILI DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 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 Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: • State Work Done I e- - 1,Pr •- <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 /> 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-became 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 df California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X' llu k wn Title: <br /> (Draw Plot Plan on Reverse Side) <br /> w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I1` <br /> Application Accepted By L Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By l 0,. Date ' Inspection By . 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE y C u <br /> LESS ~] <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 441 <br /> Received by Date Receipt No. Permif•No,eA Issuan a Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 3 <br />