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applications Will Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE., APPLICATION <br /> (For Non-Transferable,r Revocable,�Su�spendable) <br /> ENVIRONMENTAL HEALTH Pf PUMP ,WELI <br /> (COMPLETE IN TRIPLICATE) WATER 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 wi77-, <br /> h,5an a�}ui Countyy,pr ina 1862 d e rules and regulations of the San J um Loc l Health District. <br /> Exact Site Address 7 I- r - � 7 c-.� ' <br /> City/Town <br /> Owner's Name �- ��.�.�% J'�'t..~�` � <br /> fPhone *� <br /> Address ` ZtpJ. <br /> City <br /> Contractor's Name . <br /> License# 7business_P n 6 ' <br /> Contractor's Address " 't �"' u r <br /> Emergency Phone �' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C] ^' PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED - Dia. of Well Casing <br /> F-1 DOMESTIC/PUB LIC ❑ 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 SurfaGe)Seal InstAllgd By: <br /> PUMP INSTALLATION: Contractor ? `' <br /> Type of Pump ,�"` �=�� H.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 /> 1 <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit t <br /> is issued, I shall not employ any person iri 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 /> permiti1Y is issue-ef'shall employ persons subject to workman's corn tion laws of California." <br /> # � <br /> I will caltit}r a {�atlt Inspection prior to grAuting and a final inspecti$ . <br /> Signed XG/ Title: '{ 'cr• a -' <br /> Date: <br /> (Draw Plot Plan on%Reverse Side) ' <br /> FOR 1SEPARTM NT USE ONLY <br /> PHASE l �< <br /> �.. <br /> Application Accepted By bate <br /> Additional Comments: <br /> Phase Il Grout Inspection Phase"III Final Inspection <br /> Inspection'By Date Inspection By Date r <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> REMIT <br /> DATE DATE REMITTED AMOUNT FEE ����. y�"y� �. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> M $ - 4 <br /> Received by ate Receipt No. Permit No. ssuanceate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />