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.. .. �_ <br /> ,�; y pp Ica robs Will Be Processed When Submitted Properly Completed. Be u i T plication. <br /> FOR OFFICE_I.;E: APPLICAT(O <br /> (For Non-Transferable, Revoc �e� e alit ) <br /> l5il! PUMP&WELL 2 <br /> ENVIRONMENTAL HEA PERN�T2 , _- <br /> (COMPLETE IN TRIIPLICATE) j WATER QUALITY A <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or t t cM�� <br /> kLJ} }v �'�,Jealfth <br /> described.This application is <br /> made in compliance wit��n Joal uin oun rdi a ceNo. 186 nd t e rules and re } ' �1e- � t't District. <br /> Exact Site Address own �/ <br /> Owner's Name 4� Phone �6 I' " 172C <br /> Address _ <br /> City <br /> Contractor's Name License#,L(p'��_ Business Phone�� <br /> Contractor's Address t Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance oll With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINAT ON 11 WELL ABANDONMENT ❑ OTHER E] PUMP INSTALLATION El PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Se tic Tank vv�V <br /> P 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 j ❑ CABLE TOOL T'" Dia:of Well Excavation - <br /> DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 11 IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal I stalled By: <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H P i <br /> PUMP REPLACEMENT: __R-'State_Work Done <br /> 1 <br />., PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter„ <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that.I have preparl' applicafion and that the work will be done in accordance with San Joaquin County. I <br /> o.rdinances,_state laws; and rules and re ulatrons of the San Joa uin Local Health District. (J1 <br /> Home owner al licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit <br /> is issued, I shalt 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 performanceof the work forwhich this <br /> permit is issued, I shall lemploy persons subject to workman's compensation laws of California." <br /> I will 1I)or a Grout Inspection prior to outing and a final•.inspection. <br /> Signed X �i. <br /> Title:, Date: <br /> (Draw PI an-on Reve a Side) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> i ! r i• <br /> Application Accepted By ^— <br /> Additional Comments: Date!�� <br /> Phall Grout Inspection Pb a Ill Fina`Inspection <br /> Inspection By I Date fns Inspection 13 <br /> p Y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31Y <br /> � Y El July 1 &Received By July 31 <br /> BASE �. EXPLANATION BILLING REMITTANCE $ - REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED f <br /> AMOUNT <br /> FEE S./ I� 4 �� Q <br /> LESS <br /> PRORATION <br /> PLUS �II <br /> PENALTY yI r <br /> OTHER ^' <br /> OTHER - - - - - <br /> Received byDa[e <br /> :III Receipt No, Permit No. - Iss nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES`TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />