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FOR OFFICE-USE: APPLI -A 3, le`or Non-Transferabl o pj , <br /> ENVIRONMENT EALTH PERM PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATE 1.14EB 7 {�8� <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstructa ,fps I0orkhereindescribed.Thisa{iplicationis� <br /> made in compliance with San Joaquin Count Ordinance No.5 a2ai_71862 and the rulg l r��$1�8MVrn Joaquin Local Health District. <br /> Exact Site Address p t1y own <br /> Owner's Name r►t-0 •G Phone <br /> Address 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❑ DESTRUCTION❑ j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER 13 PUMP INSTALLATION 13 PUMP REPAIR 0 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br />' I 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 N <br /> ❑ DISPOSAL a ❑ OTHER Other Information_ ___ C4 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> it 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 it <br /> Describe Material and Procedure <br /> ,II <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 /> 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 /> permit is issued, I shall-employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting <br /> and a final inspection. <br /> Signed X JI L+ itie: Date: <br /> r kQ <br /> _ <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPART ENT USE ONLY <br /> PHASE { - <br /> Application Accepted By Date <br /> Additional Comments: <br /> - I Ph a Grout inspection P se ll Final Inspection <br /> Inspection By Date Inspection By -cmn Date <br /> l� , <br /> Fee Is Due:;❑ ANNUALLY ❑ PER UNIT 07 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> A DATE DATE REMITTED ,ry AMOUNT <br /> 'i FEE <br /> LESS J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> ,. 3 <br /> Received by ;i pate Receipt No. -Permit No. Issuance Date Mailed Delivered <br /> T <br /> APPLICANT—: RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES 1601 E.HA2ELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />