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ApplicationsWill Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i` FOR OFFICE USE: APPLICATION ` <br /> ` (For,Non-Transferable, Revocable, Suspen <br /> " PUMP&WELL , <br /> ENVIRONMEN,F4l�q,Aik�4 <br /> (COMPLETE IN TRIPLICATE) 1fTY - <br /> i Application is hereby made to the San Joaquin Local Health Distri permittoco sru �orinstall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 18 the aegulations of the San Joaquin Local Health District. <br /> Exact Site Address WLwn _X� <br /> Owner's Name _� Cr�I��rFi 50-P, tN1,;:T d-ne - )0,02 1, <br /> Address City <br /> Contractor's Name _�� _ wmaa� License# f �3_ Business Phone ��• s' <br /> Contractor's AddressEmergency Phone I <br /> 'Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Irl PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy l <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <br /> rj <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑�NVDUSTRIAL ❑ "' Y <br /> [ CABLE TOOL Dia. of Well Excavation"^^^"� <br /> IJ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing. <br /> 4 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T <br /> ,. z <br /> ❑ DISPOSAL ❑ OTHER Other <br /> of Grout <br /> Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Ty ee of Pump H.P. 4 <br /> PUMP REPLACEMENT: IJ State Work Done �1� .,,t�� XL <br /> PUMP REPAIR: ❑ State Work Done �c <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ` 1 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Xl ?» lal+®._ry.. ) Title: Date: <br /> _(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> r _ 1 <br /> Application Accepted By Date <br /> t <br /> Additional Comments: <br /> Phase 11 Grout Inspection P s i I pection <br /> F <br /> Inspection By Date Inspection By Date <br /> F Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BILL#NG REMITTANCE -$ REMiT - <br />~ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED _- <br /> AMOUNT ' -7- <br /> FEE E FEE <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a <br /> Received by Date Receipt No. Permit No. Issu nee D to Mailed .Deiivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9520 <br />