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-`-iAppllcallons Will Be Processed When Submitted Property Completed. fie I QpIg Appimaxion. <br /> A OCFICE Use: APPLICA �e b�� <br /> (For Non-Transferable, Re le e) PUMP&WELL -� <br /> �. ENVIRONMENTAL H TH NEEI�NIIT 19 79 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ��JJ JJ N <br /> rein described.This a lication is <br /> Application is hereby made totheSanJoaquin Local Health District fora permit toconstructa d,-�r�r}sJt�t(Ith_PC PP r <br /> made in compliance with San Joa uin Count Ordinance No. 1862 and the rules atti c Ill t�ti))g1ri o� i �(' `,q�uln cal Health District. O <br /> Exact Site Address f .;` 2_.�-!` - 1tylTown <br /> Owner's Na,m`e"- _ Phone <br /> Address �_ City - <br /> Contractor's Name — c.� License#/,13.23 Business Phone��� r <br /> I ' '�,( Emergency Phone _..TSe�r- I;. 2�- <br /> Contractor's Address �_!`f�--->Q-�- -_`i � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ lll,J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 52" OTHER ❑ PUMP INSTALLATION C1PUMP REPAIR 6 <br /> REPLACEMENT❑ i. <br /> DISTANCE TO NEAREST: Septic Tank -'-` 0 Sewer Lines _ Pit Privy r <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 /> —�►i <br /> ❑ DISPOSAL ❑ OTHER _ _ Other Information —7 <br /> ❑ GEOPHYSICAL Su face Seal Installe By: <br /> PUMP INSTALLATION: Contractor_ � - <br /> Type of Pump - -«gy p H.P :3 b <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 taws, 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 lorwhich 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:1 certify that in the performance of the work(or which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w/llJ1,'�,II for a Grout In ection prior to outing and a final Inspection. <br /> Signed X 'rJ �� -- Title: //^ _ Dale: 1 � <br /> (Draw Plot PI an on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI / q <br /> Application Accepted By _ Date <br /> Additional Comments: i <br /> Phase II Grout spec on Phase III Final Inspection <br /> Inspection By Date Inspection By - Date <br /> Fee Is Due: ❑ ANNUALI Y ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan,ary 1&Received By January 31 ❑ J,ly 1 b Rice ved By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHCCKED <br /> DATE UAIE REM1TTFD AMOUNT <br /> FEE «. <br /> — -:)4 <br /> LESS <br /> PRORATION _ __. <br /> PLdti <br /> PENALTY <br /> U f HER � � � � _-� <br /> ('THEn <br /> '79 l oto _—,{�151.E _. <br /> Received by Date Receipt No. Pe. mit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT�SERVICES 1501 E.HAZELTON AVE.,P.O.Bo.2009 STOCKTON,CA 95201 <br />