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Applications Will Be Processed When Submitted Properly Completed.14 Ire To Sign The A pli�$tia+�.� <br /> FOR OFFICE USE: APPLICATION Oct "moii' (J�� <br /> r (For Non-Transferable, Revocable, Suspendable) 19" ' <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMAN Jp,¢,QUjN <br /> A R QUALITY HEAL.rN D! LOCAL <br /> I <br /> (COMPLETE IN TRIPLICATE) <br /> ' DIS <br /> is hereby made tot eSanJoa e,�liia_ ist�_ ri t ermittoconstruct and/or install the work herein d�st ribed.This application is <br /> made in compliance with San Joaquin County OrdiNo. 62 and the I s a�n�d!regul 'ons of the San Joaquin Local Health District. <br /> Exact Site Address nanc V or w• _ City/Towne SSL 4,0�7 <br /> �� +\ C7p � <br /> Owner's Name / c , r de �hone <br /> Address Y 111 Cit ,-SG;OL'D <br /> _ <br /> Contractor's Name �. _ License#c,27�0/Z Business Phone,"_ •A ?� <br /> Contractor's Address _r_E9 E i j'/�il/i� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on f=ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13DFEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRII <br /> REPLACEMENT❑ S <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy H <br /> Sewage Disposal Field "Cesspool/Seepage Pit _ Other <br />` Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 52 State Work bone OIs <br /> DESTRUCTION OF WELL: Well Diameter pproximate 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:1 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 subiect 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 /> I call for a Gr ins clion prior to grouting and a final inspections. <br /> Signed X Title: Date: !2-.27-1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI / <br /> Application Accepted By a�� Date <br /> Additional Comments: <br /> i Phase It Grout Inspection Pha Final I ection <br /> Inspection By Date Inspection By ate ld <br /> Ox If <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT PEA SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMfT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> I � <br /> FEE Lj <br /> LESS <br /> PRORAT*N <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cewed by-"-*-__ Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> '0111LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOW 95201 .�, <br />