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1pp'cations Will Be Proessed Wien Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> FEB 81 APPLICATION <br /> (Foorp,Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> Iii�FVIRONME{VTAL HEALTH PERMIT <br /> HEALTH DISTRIX,I <br /> (COMPLETE IN TRIPLICATE) ,fWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address A,,,7-4 9; City/Town <br /> Owner's Name n yz a, Phone ljIA <br /> Addressmom,. City-- �BC..,440•1 ^ <br /> Contractor's Name License#. W49 Business Phone <br /> Contractor's Address 0 3_4a2 ,;9/ = Emergency,PJh1one f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�� No <br /> TYPE OF WORK (CHECK): -'NEW WELL❑ DEEPEN ❑ RECONDITIOND' ` DESTRUCTION❑ — <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: + Septic Tank Sewer Lines Pit Privy <br /> 1 - <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑a 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.. W.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:"I certify that in the performance of the work for which this permit r <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 /> I will htor a Grout 1 p�ctio ho to grousing and a final inspects <br /> Signed X Title: Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' 'p►p►p►y}}}fi�?4,, (� ] <br /> Application Accepted ByDate " <br /> Additional Comments: <br /> Phase II Grout Inspectionbase I I Inal Inspection <br /> Inspection By ln. Date Inspection By DateQ''Iffly <br /> Fee Is Due:-1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1'&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED " <br /> AMOUNT <br /> FEE q,C� <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY, <br /> OTHER <br /> OTHER <br /> f <br /> Received by, bale 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 2049 STOCKTON,CA 95201 'Zj(3J <br /> i <br />