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App' Be ProcesNlen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: C( �,nJ F ".%APPLICATION <br /> Q \ ( 4Q(,7L insferable,Revocable, Suspendable) <br /> PUMP&WELL <br /> eft" ��i <br /> MENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) `•/ . �. � WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin nCourt y Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /��iS'��t , [[ Gt�a�.� City/Town(] �1B,g� ��l33 <br /> Owner's Name .�� Phone � 2 <br /> Address City -» O <br /> Contractor's Name :aaa4je& 14 License# G(z Business Phone P2 1-1W4 <br /> .f./CLL/ <br /> Contractor's Address f7.r2Z�2!V6, A"4_ , �.�. Emergency Phone a7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �9 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR B' <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well 93'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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 50 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 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 calllff r a ut Inspection prior to grouting and a final inspecti <br /> Signed X i�^r Title: Date: G %� <br /> (Draw Plot Plan on Reverse Side) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I w- `� •10-a3-8o <br /> Application Accepted By w �`-' Date <br /> Additional Comments: <br /> Phase II Grout Inspection / as III Final Inspection �---�� <br /> Inspection By dV1 i n Date_ Inspection By ` . Dater <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 /> FEE �5CICO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />