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_ FOR OFFICE USE ,�,' YAPPLICATION -- <br /> a.� '�"' Non-Transferable, Revocable,Suspendable) PUMP-Az-WELL <br /> �„VO N AL HEALTH PERMIT <br /> n/, `" WATER QUALITY J : 2-C3 —1, 0—C2 <br /> (COMPLETE IN TRIPLICATC- ,s t.-11i i }fl ) Q <br /> Application is hereby madetoth Bafi4oaq[1irfL0cal I46alth District for a permit to construct and/or instal I the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � City/Town G6 <br /> ' i�1, I <br /> Owner's Name a-' r Phone , " `•� � � � A <br /> Address City <br /> Contractor's Name License# Business <br /> Contractors Address MLhFLWEmergency Phone _____9J <br /> Is Certificate of Workman's Compensation Insurance on Fite With SJLHD? Yes �- No j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEM ENT❑ <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 /> 4r INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a <br /> I❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> yr IRRIGATION1 13 GRAVELPACK Depth of Grout Seal <br /> T C <br /> ❑ CATHODIC PRO ECTIN ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information '�• <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: 6 <br /> PUMP INSTALLATION: ContractorC-�.1�G�aLB+ <br /> Type of Pump ! <br /> =.mo� 4w� H.P. IV <br /> PUMP REPLACEMENT: .❑ State Work Done .( (I <br /> PUMP REPAIR: W State Work Done i4Ir <br /> (1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Deplf <br /> m <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 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,jwij/call for Grout IWipection prior to grouting and a final Inspect <br /> Signed X Title: Date: � '7/A2s <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B „. Date <br /> Additional Comments:_C YTy&"l rv,nE 5ACAP4 cwt <br /> cta <br /> 't� <br /> _( <br /> Phase 11 Grout Inspection pection <br /> Inspection By--N) 1� Date Inspection By DateA <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE {t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A <br /> Received 4y Dete Receipt No. Permit No: Iss rice a e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />