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AppElcatlorls°W1ff 13906essed hen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE U9 APPLICATION <br /> APPLICATION ' <br /> "hereb <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> NVIRONMENTAL HEALTH'PERMIT <br /> '(COM WATER QUALITYAppEi �SanJoaqulnLocalFiealthDistrictforapermittoconstructand/orinstall the workherein described,This application is <br /> made in compliance with San Joaquin otty Ordinance No. 1862 and the rules and regulations of the an o quin Local Health D�trict:' <br /> Exactt,Site.ALddress. <br /> � T <br /> Owner's Name` Ah- Phone <br /> Address , . a City <br /> Contractor's Name `-License# Business Phone 5--1 <br /> Contractor's Address � � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - _ No ) <br /> TYPE OF WORK (CHECK): ' NEW WELL DEEPEN ❑ -" RECONDITION❑ DESTRUCTION E] - <br /> WELL-CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Ag- <br /> REPLACE MENT <br /> g—REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 116 11 e, Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE t TYPE OF WELL 1) <br /> ElINDUSTRIAL E] CABLE TOOL Dia. of Well Excavation _ . <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0--DRIVEN t Gauge of Casing 1-,6 0 W�'& - <br /> ❑ IRRIGATION rye,GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION .wl ROTARY Type of Grout <br /> ❑ DISPOSAL 13 OtTHER w# . Other Information y� <br /> 11 GEOPHYSICAL- . '. 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '+ -7 * .r <br /> Type of Pump {_ H P <br /> PUMP REPLACEMENT: _. ❑ State Work Done i ' 44-'r t -` <br /> ❑ State Work Done r i <br /> PUMP REPAIR: _ '� ""`"-' ' <br /> DESTRUCTION OF WELL:- Well Diameter r.f Approximate Depth <br /> Describe Material and.Procedure <br /> t <br /> 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 forwhich 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 /> - <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for Grout Inspe n prior to gr Uting and a final inspecfi <br /> _ I <br /> Signed X Title: Date: / 7 rt <br /> ( a' Plot Ian on Reverse Side) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - t d-g 1 <br /> Application Accepted By. _ Date <br /> Additional Comments: <br /> Phase fl Grout Inspection Ph se III Final Inspection <br /> Inspection By Date I �� Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED' AMOUNT <br /> FEE <br /> LESS <br /> PROBATION I <br />> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 � - [ a 3 <br /> Received by Da Receipt No. Permit No,. �_ 4_, Issuan a Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />