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Applications W;II Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, otab a SF(9pe a e) PUMP&WELL <br /> l <br /> ENVIROa� WE' <br /> 1 li QUALITY a. <br /> {COMPLETE IN TRIPLICATE} . ,^� ,t •� $ <br /> �. Bt1 2 <br /> Application is hereby made to the San Joaquin Local Health Dist26t,2' <br /> apei No rsl�s uctand/orinstalltheworkher.,. . cribed.ThisappGcationis <br /> made in compliance with San Joaquin County Ordinance No. and the rr''ules and'regulaii�bf the San Joaquin Local Health District, <br /> Exact Site Address o r � /Town <br /> Owner's Name ° Phone 3 a <br /> Address 1 S d se, 'n c�c;���� City <br /> { f7_Business-Phone <br /> Contractor's Name �G�.v _ �.C�r*�-F�_ � � _ License#! 6��7 _ � y <br /> Contractor's Address _� 6,4 !9, J 'Emergency Phone ; (T ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW VIIELL 13 DEEPEN ❑ RECONDITION❑ W DESTRUCTION❑ ( n ? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION❑ PUMP REPAIR V L <br /> REPLACEMENT❑ l <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 ri - TYPE OF WELL - <br /> ❑ 1VDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation j <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <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 /> i <br /> Type of.Pump H:P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> PUMP REPAIR: [g'State Work Done w <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure, '� <br /> 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 orsub-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 call for a Grout Inspection prior to grouting and a final inspection. <br /> ' 6 <br /> Signed X �`I itle: Date; <br /> 1 - <br /> {Di•aw Plot Plan on Reverse de) <br /> ll FOR DEPARTMENT USE ONLY <br /> PHASE I I. .� . : a <br /> Date o- .� CJo� <br /> Application Accepted By <br /> Additional Comments: <br /> ow- <br /> Phase II Grout Inspection s 11 Final pection <br /> Inspection By <br /> Date Inspection By DaICA — WAte r 2 <br /> I <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 /> 'BILLING REMITTANCE $ AMOUNT DUE CHECKED- <br /> - <br /> BASE EXPLANATION DATE DATE REMITTED, AMOUNT ` <br /> A4 <br /> �FEE5 <br /> PRORATION ` <br /> PLUS <br /> PENALTY r <br /> OTHER <br /> OTHER <br /> ... ' b <br /> Received 6y Date Receipt No. Permit No I uance ate..•- Mailed Delivered, <br /> APPLICANT—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Bo:2009 STOCKTON,CA 95201 - <br />