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FOA OFFICE USE: APPLI6AF14NI���I li L <br /> �,r Non-Transferable, Revocabl�l 5'dspendable) <br /> PUMP&WELL <br /> ENVIRONMENTALWATER QUAFigALTHLITYl5� <br /> IT1g$O` R <br /> (COMPLETE IN TRIPLICATE) ,�, �� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cop§truct find/pPi hVNI1I th'el"Wherein described.This application is <br /> made in compliance with San Joaquin County, dinance No. 1862 and the rules Ad'regulatir s fl lfi§t3a aquin I- cal Health District. <br /> . t..,:_r... <br /> Enact Site Address ���� ® � _ _ _ City/Town <br /> —:36 S <br /> Owner's Name - Phone '79___ <br /> Address 6 tl r City L[e <br /> Contractor's Name LicenseN� 52 Business Phone�oS � <br /> Contractor's Address Emergency Phone tK�6� ec_- 99 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No ___ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDITION❑ DESTRUCTION❑ C <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 111 I <br /> REPLACEMENT 8� L <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 /> ❑ GEOPHYSICALS ace Seal Installed y: __. AM <br /> PUMP INSTALLATION: Contractor 6 <br /> Type of Pump U.P. 0 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California." <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, 1 shall employ persons subject to workman's compensation laws of California." - <br /> I I al for a Grou peclian prior to uting and a final Inspection.2! <br /> Signed X Title: le-AZ Date: <br /> (Draw PI t-Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY L <br /> PHASE <br /> Application Accepted By �� — Date -- v <br /> Additional Comments: -- <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By, <br /> 61, Date � "oZl- 9— <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 7 <br /> PRORATION - _— <br /> PLUS <br /> PENALTY - -- <br /> OTHER <br /> OTHER <br /> Oi�`Io4 `7/ g1Fo <br /> Received by <br /> Date Receipt No. Permd No. Iss ante Oate M Iled Oe1 red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA3ELtON AVE.,P.O.Be.30011 BTOCKTON,CA <br />