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-7 Applications Will Be Processed WhenSubmitted ProperlyCompleted.Be wre Iobi ppucarton. <br /> 11 <br /> FOR OFFICE USE: = ."" n APPLICATION <br /> (For Non-Transferable, Revocabl "Pe a% PUMP&WELL <br /> ENVIRONMENTAL H T,; RMIT <br /> CONtPLE TRIPLICATE "A'ER QUA <br /> r <br /> Application is hereby made eSanJoaquinLocalHealthDistrictforapermitto struct5orinstallthevlr, *eindescribed.Thisapplicationis <br /> made in compliance w' an Joaquin County Ordinance No. 1 62 and the rules and regulati ras `i0 in�Local Health District. <br /> Exact Site Address � � �1 + <br /> Owner's Name Phone � <br /> Address City l <br /> Contractor's Name 1 License #/ _.� Business Phone <br /> Contractor's Address =2 n::k,.. Emergency Phone r �a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ c , <br /> REPLACEMENT�� V <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i <br /> Sewage Disposal Field -,Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE =,i TYPE OF WELL, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION '❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 4. . - Type of Pump— ce;�.4�.����sr �4 H.P. ' <br /> PUMP REPLACEMENT: * __ l;-State Work Done # <br /> 1 <br /> PUMP REPAIR: ❑ State Work Done <br /> - -^=-�^c- �—.. - "- -- �A rozimate be th <br /> -DESTRUCTION-OF,WELLr--^' W611 Diameter pp P <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> an person in such maas to become subject to workman's compensation laws of California." <br /> is issued, I shall not employ y p n_ �j <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 /> a 4 <br /> willc for a Grout Inspe 'on prior to gro ting and a final inspection. '- w <br /> Signed X Title: j ,�. Date:,? <br /> (Draw PI n on RNever <br /> 1, FOR DEPARTMENT USE ONLY <br />' PHASE <br /> ��. <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Final Inspection j 1 <br /> Inspection By Date Inspection By D e 7� (/ <br /> Fee Is Due: 1.1ANNUALLY ❑ PER UNiT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 EJ 1 &Received By July <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br />' DATE DATE REMITTED AMOUNT <br /> FEE 0ys— <br /> , <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> k - OTHER'S"".,-- -- - --. .. <br /> OTHER <br /> t � � IqlaaF <br /> a Received by Date Receipt No. Permit No. ssuance ate Mailed Delivered i <br /> t, APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201. <br />