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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION p-1 sr <br /> (For Non-Transfe'rable,'Revocable, Suspendable) PUMP&WELL I <br /> r0 V ENVIRONMENTAL-HEALTH`PERMITL { <br /> WATERQUALITY <br /> OMPLETE IN TRIPLICATE) �:. f.. '�i:., <br /> (Ct5&G? `f7 <br /> ^', • • ';, "' -� <br /> a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work,herein-described.This application is <br /> made incompliance with San Joaquin pounty Ordinance No. 1,862�!and the <br /> _�ules and regulations of the Sawn Joaquin Local Health District. 1 <br /> Exact Site Address -�� `' r IC11T' f City/Towns 1 <br /> Owner's Narrie Y1_ �f - -c Plione "k <br /> ,y <br /> Address ,f^ t _ ,�f. : Cy ,xs . <br /> Contractor's Name License#:iia 6Business Phonef-,". <br /> Contractor's Address <br /> �'Ernergency Phone-6 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ _ _ <br /> TYPE OF WORK-(CHECK): NEW WELL❑ DEEPEN-❑' RECONDITION❑ T—DESTRUCTION©�/ w <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 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 /> ❑ I STRIAL 11CABLE TOOL Dia. of Well Excavation <br /> 9-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13-DRIVEN t 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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane �t'l <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well.Diameter Approximate Depth <br /> Describe Material and Procedure`N <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 thwork for which this permit <br /> is issued, I shall not employ any person in such.manner as to.become subject toyworkman's compensation laws of California." d� <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca or Grout-Inspec on prior to grouting and a final inspection. �- r <br /> < Title: "..c.P,��_� Date: <br /> Signed X - -• <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By �� ' - Y Date <br /> Additional Comments: <br /> F Phase 11 Grout Inspection Pha !nal Inspe tion/ <br /> Inspection By Date Inspection By <br /> =t <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PERSITE ❑ EACH:- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July31 <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> IV L�sFEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER > <br /> Received by - Date y- = --Receipt No- Permit N6. - : ..Issban a bate - Mailed.- Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />