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Applications WI. ed When Submitted Prop 1 �e ighe Application. <br /> FOR OFFICE USE: APPLIC - <br /> T (For Non-Transferable, Re le,Suspendable) UMP&WELL <br /> U0 <br /> ENVIRONMENTAL HEALTFAMIlIff 1982 <br /> (COMPLETE IN TRIPLICATE) IrXI 5,f7iy/or+% WATER QUALIIT�Yp/�� <br /> Application is hereby made to the San Joaquin Local Health District for a permit t009r1 u aI1J0thereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules a rt®IStTF Joaquin Local Health District. <br /> Exact Site Address +5 City/Town <br /> Owner's Name 41 �Gn.,./al _ Phone <br /> Address 7 D '1] �t(„est: , & city .��.✓ �a✓, <br /> Contractor's Name .�".vLT f ay License# /6,2,323 Business Phone ,g66-A-IS <br /> Contractor's Address P o-19,1 j�A4%— Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑' RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 1:1PUMP INSTALLATION 6 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 /> 0DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation A <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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> T�yp�of Pump H.P. <br /> PUMP REPLACEMENT: u State Work Done - <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 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 /> Signed X ate- )-n. 6?,, ,.- Title: Date: - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted ByAr{'G— DateL� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection B 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 9� <br /> FEE u 2 7-v <br /> LESS (/r./r✓�!le w u,.ct L <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />