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Ap 1�- ons Will Be Processed WhIDbmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE+ AUGUSE: U - 2 1902 APPLICATION <br /> ( or Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> SANOAQUIN €t LtNWNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) HEALTH DISTRICT 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 oun mance No.1862 and the rules and regulations of the SanJoaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name ,7T Phone <br /> Address -�tt�) 11 __47A liii City <br /> Contractor's Name Li ense# sin ss Phone y <br /> Contractor's Address . 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 CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 /> I ENDED USE TYPE OF WELL <br /> ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <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 /> Type ump H.P. <br /> PUMP REPLACEMENT: SWork Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 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. `O <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 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 /> 1 will call for a G Inspectio rior to gr ting and a 'nal inspectio s / <br /> Signed X it � iC�7/ Date: <br /> (Draw Plot PI verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By d3 Date <br /> Additional Comments: <br /> Phase <br /> II Grout Inspection h e III Final Inspection <br /> Inspection By—��fir.___—_ Date Inspection Date ����� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Heceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT pUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> sjR / <br /> l <br /> by Date Receipt No, Permit No, /ksuan4 Date Mailed Delivered <br /> CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />