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. .. . . ..........__. r---r <br /> Wit. vFFICE USE: APPLICA ,�j/117Af �` ! <br /> ,or Non-Transferable, Rev a Suspen`d�able) i 7� <br /> ENVIRONMENTAL HE LTH P"I�II� <br /> PUMP WELL <br /> nr AL <br /> COMPLETE !N TRIPLICATE) WATER QUALITY �n OA( {,�N 1✓` T <br /> kpplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstr�_tm �i,lRta7�t�eW�l'�t'lereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and re Ions of the Sao J uin L a Health District. <br /> Site Address �� �� City/Townrxact <br /> wner's Name) Phone <br /> Address City r <br /> r,-,-ontractor's <br /> ontractor's Name License#JJBusiness Phone <br /> Address c Emergency Phone !YC4—sG�r <br /> s Certificate of Workman's Compensation lnsuran on File With SJLHD? Yes .— No Q <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> RNELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> EPLACEMENT❑ S <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> F Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> j DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> FCATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 0 DISPOSAL ❑ OTHER Other Information IJC <br /> ❑ GEOPHYSICAL Surface Sea Installed By. <br /> UMP INSTALLATION: contractor JD _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done J <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 /> F. <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'foliowing:"I certify that in the performance of the work far which this <br /> F-i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will !1 for Grout In pe prior to grou ng and a final inspection. <br /> Fs <br /> igned X Title: !�� —_- Date: <br /> (Draw o Ian on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> I Pha a fl Grout Inspection Phase Mel Inspection) _ <br /> F Inspection By— Date Inspection B.y. <br /> Fee Is Due: ❑ ANNUALLY ❑ 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 DATE DATE .REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE J?Z5 <br /> FLESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f OTHER <br /> ]{ OTHER <br /> Cws V <br /> Received by Date Receipt Na. Permit No. ssuance Date Mailed Delivered <br /> APPLICANT—AETURN ALL COPIES To: ENVIRONMENTAL HEALTH PEAMIT111111ICES 1111 E.HAZELTON AVE.,P.O.Box 2109 STOCKTON,CA 95201 <br />