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j Applit <br /> Ai�e"ProessedWHen=IPPLICATION't <br /> itted Properly ComplMO-Be ure IosignTIIn7eKpp��p'+f 1* <br /> FOR L?�FICE USE: p OV 8 IJI9 �-.:1 <br /> NOV 15 JAndon-Transferable, Revocable, Su sp dable) <br /> E�yy�plN r�.AQJINPUMP&WELD. <br /> SAN ��AQi.�1N LUL;RNMENTAL HEALTH PEF i LTH DISTR"LO-AL <br /> (COMPLETE IN TRIPLICATE) HEALTH DISTRICT WATER QUALITY <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 is <br /> made in compliance wit rb lq� CourltyQ�d&JP A' and l2arges and regulations of the San a i LIlc3�He�jj is ict. <br /> Exact Site Address Com( JJ r�� �1"✓,` �I'`.' /�6City/Town G�_� C� <br /> Owner's Name <br /> ,� Phone <br /> Address City <br /> Contractor's Name '� ense IA � Bu in�S�Phll � p <br /> Contractor's Address _ Emergency Phone FF��6677 <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❑ j <br /> DISTANCE TO NEAREST: Septic Tank ` Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I` ❑ 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 i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. { <br /> PUMP REPLACEMENT: <br /> El State Work Donele All <br /> i PUMP REPAIR: g?State Work Done <br /> f DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> F <br /> l l 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 /> Home owner 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 c that in the performance of the work forwhich this <br /> permit is i I shall a oy ersons subject to workman's compens i that <br /> of California." <br /> it out Insp ion rior to grouting and a final inspecti 57_ <br /> Signed X Title: Date—"7 <br /> I (Draw Plot Plan on Reverse Side) <br /> FO DEPAR MENT USE ONLY <br /> PHASE I7 <br /> Application Accepted ay Date 7 <br /> Additional Comments: <br /> Phase II Grout Inspection a e 111 Fi al Inspection J �. O <br /> I Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received 8y January 31. C] July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r✓ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '7ljls �� <br /> I Permit No. Iss ance Date Mailed Delivered <br /> Received by Date Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br />