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Applications Will Be Processed When Submitted Properly Completed. ftireToSign TheApplication€� <br /> FOR dFFICE USE. APPLICATION .JAN 3 gi 1980 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> AN � r.{ Lf ll PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERM L01CAL <br /> WATER QUALITY HEP TN DJSTR'ICT <br /> (COMPLETE IN TRIPLICATE) qA <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 ism <br /> made in compliance with San Joa uin County Ordinance No. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address fA1,9- '57— City/Town` <br /> Owner's Name �� �_ Phone � "l <br /> Address tp �7f�/ City <br /> Contractor's Name License ;_37Q5YZ_, Business Phone :5 3-7 7_ <br /> Contractor's Address &y4L--Ar 77> 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 4!�2 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line��v f Private Domestic Well 7742'- Public Domestic Well <br /> INTENDED USE Ivf TYPE OF WELL _ <br /> ❑ INDUSTRIAL 1a 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: P"_L .Iw <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 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:A certifythat in the performance of the work for which this permit <br /> is issued, l 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 wit call fora G out Ins pec io pr'or to grouting and a final inspection. <br /> Signed X , Title: Date: OQ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: _ <br /> (P�hya�se II Grout Inspection r� `J: Phase I Final Inspection <br /> Inspection 8y �1k�k dbr-i, - Date ¢ "$0 Inspection By Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED z AMOUNT <br /> FEE —5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, I uance Epte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />