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ApplicationsWill BeProcessedWhen Submitted Properly Completed. BeSpfe nTheApplication <br /> FOR GFFO-RE USE: APPLICATION <br /> (For Non-Transferable, Revocabl :lZERM1 <br /> es eJ <br /> PUMP&WELL <br /> ENVIRONMENTAL T <br /> a <br /> (COMPLETE IN TRIPLICATE) WATER � �-t <br /> A ppl ication is he reby made to t he San J oaq ui n Local Health D ist rict for a pe rm i t strl6nd/orinst` tNgr herein described.This application is <br /> made in compliance with San Joa uin County O iinaanu No. 1862 and the ru s and regulatip Ct � ®Jo um oval Health District. <br /> Exact Site Address �p� C�19(TbWiin <br /> Owner's Name ��r i ��'�Phone 3 ^�� <br /> Address' City <br /> Contractor's Name License#/"3 73 Business Phone 3�{ <br /> Contractor's Address l Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �, f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �e <br /> Property Line Private Domestic Well Public Domestic Well <br /> w <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation -I <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBLIC 11DRIVEN 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 Srface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 2State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - -- Describe Material and.Procedure <br /> - a <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 /> .j <br /> I w' all f r a Grout In3p tion prior to Oouting and a final inspection. Q" <br /> Signed X Title: 23, Date: Q <br /> (Draw Plo on Reverses e) i <br /> FOR DEPARTMENT USE ONLY �- <br /> PHASE I � <br /> Application Accepted By7\ Date fl —��'— <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By 1n Date Inspection By f Date J <br /> I�� <br /> Fee Is Due: 11ANNUALLY ElPER UNIT El PER SITE 1:1 EACH 1:1 January 1 &Received By January L� Iy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASF' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss nce Ogle Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTQN AVE.,P.Q.Box 2009 STOCKTON,GA 95201 <br />