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ApplicationsWill Be Processed When Submitted Properly C " t40 16% f n e ation. " <br /> FOR OFFICE USE: li APPLICATIO #�J k 'f <br /> -. (For Non-Transferable, Revocabl pendable) <br /> ENVIRONMENTAL HEALTH PERT I� <br /> 29 1981 PUMA&WELL <br /> F- (COMPLETE IN TRIPLICATE) WATER QUALITY I Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstru rITgsdescribed.Thisapplica#ion is <br /> made in compliance with San Joaquin County Ordinance No 1862 and tfie:rules and regu I n 'thea J�00 <br /> Local Health District. <br /> Exact Site Addres's r i'A <br /> _ II,� s T7 <br /> Owner's Name i t 11 ti �� Phone E L4S—l&q4- <br /> Address �. � iYYI I Y) ( ity <br /> Contractor's Name d. License # usin s Phone r <br /> Contractor's Address Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance.on File With SJLHD7 Yes No i <br /> TYPE OF WORK (CH CK): NEW WELL❑ DEEPEN ❑ RECONDITION.❑ DESTRUCTION❑ <br /> €WELL CHLORI'NK ON.01% . WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I REPLACEMENT i <br /> DISTANCE TO NEAREST: Septic Tank ! Sewer Lines Pit Privy <br /> 3 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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. 4 <br /> PUMP REPLACEMENT: State Work Done��j �! _� r <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 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 folio ' g:.1 certify that in the performance of the work for which this <br /> pe it is ' I shall employ person ject to rkman' pensation laws of California." <br /> call fo a Grout Ins cti pr' r o groutin nd a fi spection. <br /> Signed e: Date: <br /> (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> HASE I c <br /> Application Accepted By Aftbate —d�'Fcl <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a IIII Fi Inspection <br /> Inspection By Date Inspection Date <br /> Fee.Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By nuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITT AMOUNT DUE CHECKED i <br /> 4 <br /> uC AMOUNT <br /> FEE .e... :l .. <br /> Alf <br /> Y G� <br /> LESS ,�- <br /> PRORATION Wits <br /> PLUS I <br /> PENALTY j r ' <br /> OTHER ; .. ✓�L. s. <br /> OTHER L <br /> Q1� > 1116 l <br /> Received by _ Date ii Receipt No. Permit No, Issuance 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 />