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P a it se Processyd When Submitted Properly Completed. Be Sure To Sign The Application. <br /> E FOR OFFICE USE: Gla Ng APPLICATION <br /> j�,� (FQr j Tansferable, Revocable, Suspendable) <br /> y3- Q\A jk44&MENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) SP� N\1 WATER WATER QUALITY <br /> Application is hereby made to theSan`IAuin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqu n C my Or 1 0. 1862 and the rules and regulations of the San J aquin Local Health District. <br /> -3Exact Site Address <br /> r ,is"�V't.t� 'd a S <br /> Owner's !Name City/Town� Q i` Phone <br /> Address <br /> City <br /> Contractor's Name 0 License# Business Phone t <br /> Contractor's Address � �= ?S <br /> Emergency Phone <br /> Is Certificate of Workman's Co pensationins ranee on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELNo <br /> L DEEPEN ❑ RECONDITION❑ DESTRUCT ON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> REPLACEMENT PUMP REPAIR❑ <br /> El <br /> DISTANCE TO NEAREST: <br /> Septic Tank != <br /> p Sewer Lines Pit Privy <br /> Sewage Disposal Field r Cesspoo[/Seepage Pit Other { <br /> Property Line *,D r Private Domestic Well �" Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIA]_ ❑ CABLE TOOL Dia. of Well Excavation F1. <br /> P<POMESTIC/PRIVATEDRILLED Dia. of Well Casing ri'I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> CATHODIC PROTECTION GRAVEL PACK Depth of Grout Seal Ir <br /> ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur <br /> Contractorfac eal Installed By: t <br /> PUMP INSTALLATION: + <br /> Type of Pump J, L�A J2 <br /> H P �-- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter rI <br /> 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 Joa uin Count <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. q y <br /> Homeowner or licensed agent's signature certifies the following;"I certify that in the performance of the work forwhich this permit N <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I will call f r a out inspecti prior to grouting and a final inspect] <br /> Signed X <br /> Title: <br /> Plot Plan on Reverse Side) Date: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection p f I al ns ec 'on <br /> Inspection By Date0 no <br /> Inspection Byl ate <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received By January 31 ly 1 &Received$ - <br /> yJuly 3t <br /> BASE- EXPLANATION BILLING REMITTANCE $ REMIT <br /> I DATE DATE REMI AMOUNT DUE CHECKED <br /> FEE C�- <br /> /, 3A AMOUNT <br /> � , <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER <br /> Received by ate Receipt ND- Permit No - Iss ance ate <br /> Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />