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Applications Will Be Processed When Submitted Properly Completed B St"T n The Application. <br /> FOR OFFICE USE: APPLICA <br /> For Non-Transferabl o PUMP &WELL <br /> ENVIRONMENT EALTH P RM C,(COMPLETE IN TRIPLICATE) <br /> WATE L ALITYFEB iW , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a 4SIe()&%l herein described.This application isi <br /> made in compliance with San Jo quin Count Ordinance No. 186,2,aand the rulgpi�i construct <br /> JoaquinLocal Health District. <br /> Exact Site Address /.�S �S �i a.nzl .. A H;:Ai X ty7row�n eic --Was <br /> Owner's NameZfoPhone o <br /> Address City <br /> Contractor's Name License#/(i23 73 Business Phone - e <br /> Contractor's Address A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ' ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ —s <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 00 <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 N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface 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—141!_/0AP A.TA " �-Lti1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 wh ich 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 orsub-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 /> I will call for a Grout Inspection prior to grouting <br /> /nhand a final inspection. <br /> Signed X � �nt�)• �renl-I71.(,/IssmrrTiile: f f Fin CAJ Date: <br /> (Draw Plot Plan on Reverse Side)l <br /> FO EPART ENT USE ONLY <br /> PHASE <br /> Application Accepted ByDate Z <br /> Additional Comments: <br /> Ph a Grout Inspection �p se II Final Inspection <br /> Inspection By Date Inspection By � "_ 't4_ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 19 PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> SLESSFEE <br /> (es- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> OU �� 3 <br /> Received by Date Receipt No. Perms No. Issuance Date Mailed Delivered <br /> STOCKTON,CA 85301 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 3009 <br />