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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ��aqui <br /> ENVIRQNMNTAL TH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) / 5 r fJ WATER Q ALI <br /> Applicationisherebymadetoth SanLocalHealthDistrictforapermitto onstructand/or instaUthe work hereindescribed.Thisapplication is <br /> made in compliance with S J aquin County Ordinance-No,18&_ajid the rulers and regulatio ittf�eon Jo <br /> aquin Local Health District. <br /> Exact Site Address/ ��. /�-Cd 94— /vt �iC��/Town sem— 2 1 <br /> Owner's Name — �� � Phone <br /> gs^/-- 723o c ' <br /> Address /l/ City <br /> Contractor's Name License# Business Phone <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❑ DESTRUCTIO,>A� ! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ a <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 /> ❑ 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 /> h <br /> Type of Pump H,P. t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP ❑ State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth [ 0 <br /> Describe;Material and Pr cedure , <br /> I hereby certify that I have prepared this application and that the work ill 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 <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 /> ?,all <br /> s issued, I sha_11 employ persons subject to workman's compensation laws of California." <br /> foraro Inspei n prior•lo grouting and a finalinPev <br /> Ion. _SSigned X `_z ^J Title: Date: <br /> (Draw Plot Plan onse Side). <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 141 <br /> _ <br /> Application-Accepted By bate � � + <br /> Additional-Comments: <br /> �"7Phase II Grout Ins ection <br /> P ,� / f 111 Final spection �i <br /> Inspection By <br /> —Date--- _Inspection By bale AP-04-0 <br /> , .. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- —D--PERJSITF—[3-EACH'—" 3—January 1&Received By January 31 ,❑'July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ; <br /> LESS <br /> PRORATION <br /> PLUS ` _ <br /> PENALTY <br /> OTHER <br /> OTHER -?R <br /> 2 Cf 0757S ` <br /> - Received by, bate Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> _APPLICANT=RETURN ALL_CORIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />