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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> s (For Non-Transferable, Revocable, Suspendable) puN{p&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health D �, ..1 x ar <br /> 4 istrict fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinall No. 1862 and the rules and regulations of the San J quin Local Healttl District. <br /> Exact Site Address f - ` ' ` <br /> City/Town <br /> Owner's re � Phone <br /> Address d ' fi'/ a4 <br /> city. 1 <br /> Contractor's Name 4 BOSS.. _License#3723� Business Phone3 ] 1 <br /> Contractor's Address L470 G+Unn / 2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK: NEW WELL. 'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION . PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 7 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Ill <br /> 11IRRIGATION GRAVEL PACK Depth of Grout Seal 62 <br /> ❑ CATHODIC PROTECTION AROTARY Type of Grout �. ,� f <br /> ❑ DISPOSAL 00.THER T Other Information € <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Y <br /> Type of Pump GO 51 H.P. "y <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call fora Grout Inspection prior to grouting and a final inspection. <br /> Signed X -�Yt+�LtS Title: _ �C•e1rL. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> IF <br /> Additional Comments: <br /> Phase II Grout Inspection Ph se III Final Inspection <br /> Inspection By - Date Inspection By ate F <br /> Fee Is Dil ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januarys 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE - I EXPLANATION BILLING REMITTANCE .$ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' G O <br /> LESS <br /> PRORATION <br /> 1 <br /> PLUS <br /> PENALTY <br /> OTHER -_ - <br /> OTHER <br /> - -� ��� •Ism�[ � � i i , . <br /> ' Received by Date :Receipt No. ,- T-- +_- Permit-No,-- -�. - Issuance Date .. Mailed '- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 'STOCKTON,CA 95201 <br />