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ApI ions Will Be Processed W bmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: JUL 121982 APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> SA�j l fwQUPPvl MOV60NMENTAL HEALTH PERMIT <br /> HEALTH DISTRICT WATER QUALITY ;..�,. <br /> (COMPLETE IN TRIPLICATE) 11 s+: -., .,. t od •.. <br /> Application is hereby made tothe Sari Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San.Joaquin C my inance No. 1 a. the rules and regulations of the San uin LoSal He th District..% <br /> Exact Site Address ® i� , r " City/Town J <br /> Owner's Name �,t �, Phone' +� <br /> ��, + City <br /> Address <br /> Contractor's Name • I Q : License ®�Q Business Phoned " t <br /> r,ayrl <br /> Contractor's Address -if Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK {CHECK): NEW WELC❑— DEEPEN 11T RECONDITION❑ DESTRUCTION❑ VV <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR — <br /> REPLACEMENT❑ I1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> - Sewage Disposal Field -— Cesspool/Seepage Pit 'x - Other <br /> ~ Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE I TYPE OF WELL <br /> ❑ INDUSTRIAL F ,� ❑ CABLE TOOL Dia. of Well Excavation <br /> iN 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 j <br /> ❑ GEOPHYSICALrt Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t Q <br /> Type of Pump <br /> PUMP REPLACEMENT: I N ❑ State Work Done ` <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> I - Describe Material and Procedure <br /> I hereby certify that I'ha ve 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. s t ' <br /> Homeowner or licensedlagent'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 /> r <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, 1 snail employ persons subject to workman's compensation laws of California." <br /> I Illo Grp prior to grouting and a final inspecti n: <br /> Signed X y Title: Date: <br /> ,i (Draw Plot Plari on Aeverse Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � �Y <br /> Application Accepted By '.I rye- Date <br /> ,IgM � <br /> Additional Comments; <br /> Ph a a II Grout Inspection f Phase III Final Inspection <br /> +Inspection By Date $- Inspection By ' ` t�'� Date <br /> ` Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' -❑ PER SITE E] EACH' ElJarivary�I &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> R BILLING _ REMITTANCE $ <br /> BASE I EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> m AMOUNT <br /> FEE <br /> LESS • t <br /> PRORATION l <br /> .�-PLUS <br /> PENALTY <br /> r OTHER <br /> 4 <br /> T <br /> OTHER <br /> Received t,y Date; Receipt No.-- -- Permit No- - — Issuance Date.- Mailed Delivered } <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 852 - <br /> IM - - <br />