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FOR OFFICE USE: �� APPLICATION r <br /> (,;Or Nan-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District tora permitto construct and/or install the work herein described."This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 and the ruI sand re ulations of the San Joaquin Local Health`District. <br /> Exact Site Address�r -�� __ $ _"City/Tow, L4---, <br /> Owner's Name Phone ��sK <br /> Address City,., <br /> Contractor's Name Eicens0 Business Phone <br /> Contractor's Address',19,0 Alf '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 0 DESTRUCTION <br /> ILE . U <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 13l:PUMP INSTALLATION PUMP REPAIR❑_ <br /> REPLACEMENT❑ \ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit z Other <br /> Property Line Private Domestic Well Public Domestic Well\ <br /> /I�_ PED USE TYPE OF WELL . <br /> f� NDUSTRIAL ❑ CABLE TOOL. Dia. of Well Excavation t <br /> ❑ Al <br /> DOMESTIR i,ATE ❑ DRILLED Dia. of Well Casing b <br /> ❑ DOMESTIC U 1G^� ❑ DRIVEN Gauge of Casing + `v <br /> ❑ IRRIGATIO ; ❑ GRAVEL PACK Depth of Grout Seal ` t <br /> ❑ CATHODIC PROTECTIC-N ❑ ROTARY Type of.Grout t. '{ <br /> ❑ DISPOSAL ❑ OTHER her Information {. I <br /> ❑ GEOP.HYSIC�AL �- S ace.Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑.State Work-Done <br /> PUMP REPAIR: ❑ State Work Done k V <br /> DES7P=jI N OF WELL: Well.Diameter Approximate'Depth <br /> — ___.. Describelflkaterlal ancft?rocedu[e. __... _ __. ,- � <br /> I hereby.certify-that I have prepared thi 'applicat'ion-arfd that the work will be done in accordance with San Joaquin\Count ,, - <br /> ordinances, state laws, and rules and\regdlations of the San JoaquiniLocal Health District. <br /> Homeowner or licensed agent's-signature cd <br /> if the following:"I certify that in the performance o1 the work for which this perrFlit <br /> is issued, .I shall.not employ any.person\,in sLIch manner.as.to..become_subject..to w.orkman's compensation laws of..Califdga." 1 <br /> i 4 z <br /> Contractor's hiring or subcontracting sigrtature:icertifies the following:"I certify that in the performance,of the work forwhlch this! <br /> permit is issued, I shall employ persons su�bject to workman's compensation laws of California." <br /> y�; <br /> ; <br /> I will ca or a Grout In ection prior to groytingnd a final inspection. ; <br /> Signed �� Title: Date: 3".7. i <br /> (Draws Plot'Plan on Reverse Side) <br /> FOR DEP RTMENT USE ONLY 's <br /> PHASE I 1<. t <br /> Application Accepted By ' Date ,ko ; .. <br /> Additional Comments: 'S / <br /> Phase If Grout Inspection 'zA Phase I ' f Inspection <br /> Inspection By Date ` Inspection By ate ��� <br /> • tt <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 &Received By January 31 ❑ July 1 &Received By July 31. <br /> REMIT <br /> BILLING REMITTANCE- $ L <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED' <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION -h'y ^ <br /> _...M .., <br /> PLUS <br /> PENALTY 4 � ° <br /> OTHER ...... <br /> OTHER - <br /> Recv by Date Receipt No, Permit No. . ..Issuance Date Mailed Delivered' <br /> A LICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Boz 2009 STOCKTON,CA 95201 <br />