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FOR OFFICE USE: APPLICATION <br /> l [ For Non-Transferable, Revocable,Suspendable <br /> (I,.; PUMP <br /> HEALTH PERMIT , PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District''#or a permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou tyJDrdinance No. 186 In the rules and regulations of the San JoaaL" Local Health District. <br /> Exact Site Address QM go to City/Town t Ct C <br /> Owner's Name L-A fil I �d�Ci N S Phone <br /> ' Address City <br /> Contractor's Name ' I. License#_2 �CI k/3 Business Phone <br /> Contractor's Address 3.Sr���Err���/ ,� ��..rrr Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With. SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ i' RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Q PUMP.INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 2�a ___ 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 " f� p <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation / <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a •gs-0 — <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal \ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout o e! .. <br /> ❑ DISPOSAL ❑ OTHER l Other Information <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: d Cal n e Y <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter I' Approximate Depth <br /> —_ -----Describe—Material—and-Procedure <br /> 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:1 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 certlfies 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 /> 1 II forrout Inspectiop prio 1 grouting and!!a final inspection. <br /> Signed X Title: d �- Su date: tr / �0 <br /> (Draw Plot'Plan on Reverse Side) <br /> i� <br /> ii <br /> FOR SPAR MENT 7NLY <br /> PHASE <br /> Application Accepted By 1 Date <br /> Additional Comments: <br /> Phase II.Gr1t <br /> t Inspection Phase III Final Inspection <br /> Inspection By Date_7__ 7_____ Inspection By Date <br /> is <br /> Fee Is Due: ❑ ANN ALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ' BASE EXPLANATION AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE L— <br /> } LESS <br /> PRORATION - <br /> j PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> C U s7 <br /> Received by Date Receipt No 4, Permit No.' Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 <br />