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A Plicati?qs,<Will_;Se Prc;6& ubmitted Pro sfd perly Completed. Be Sure To Sign The Application. <br /> WVI <br /> FOR OFFICE USE: APPLICATION <br /> 11 I(For N� ansferable, Revocable,Suspendable) <br /> -r---I �1' PUMP&WELL <br /> A LW I J %,, <br /> 11 REC �11 jE�VIRONMEFiTALL <br /> HEALTH'PERMIT V <br /> (COMPLETE IN IPLICATE) -WATER QUALITY, <br /> Application is hereby made toWth-��VNAWA!bistrict for a permit to construct and/or install the work herein described.Thisapplication is <br /> made in c,ompliance with San A4 HnYNo. 1862 and •rules an regulations,of the San Joa Local Health District_ 0Q <br /> 4 <br /> /T <br /> Exact Sit <br /> e Adclress'�E.�� ty own <br /> Owner's Name <br /> Phone' <br /> Address <br /> Contractor's Name <br /> one <br /> License <br /> ;3 <br /> Contractor's Address Emergency6n; <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L71 No <br /> TYPE OF-WORK (CHECK): NEW WELLO DEEPEND - RECONDITION ll'--.' DESTRUCT16NEI <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR 13' <br /> REPLACEMENT[] <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> p Pit Privy <br /> Sewage Disposal Field Cessipool/see`P.Te�pit Other <br /> Property Line— Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL El CABLE TOOL Dia. of Well'Eicavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of WelliCasing <br /> El Dom I <br /> ESTIC/PUBLIC C3 DRIVEN Gauge of Casing <br /> CT IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION C3 ROTARY Type of Gr It <br /> 11 DISPOSAL 0 OTHER Other Information <br /> .......... r\ <br /> ❑ GEOPHYSICAL Surface Se !i I ZV <br /> INSTALLATION:Pump I Contractor E),g __�=stalled By: , <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0"State work Done <br /> r. <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure (A <br /> I �-�Pe A-rm'Ttl�—54 1 rg�i en-g mcr-tm- ?T I <br /> t9lth-at-i V/- ff-`J`cT5-F?f6`­nCe­W7th-STf1 Joaquin Co"Un`ty� <br /> ordinances, state laws, and rules and regulations of the-San Joaquin Local He Ith District. <br /> He <br /> Homeowner or licensed agent's signature certifies the following: he performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject,ito workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I cerlify1that in the performance of the work forwhich this <br /> I permit is issued. I shall employ persons subject to workman's compensation I ives of California." <br /> I will call-for,a Grout Inspection prior to grouting and a final inspection.- <br /> Signed Xi2-- <br /> Date: <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Date <br /> Additionaf Comments'—__ <br /> Phase 11 Grout Inspection Final In*pection <br /> -Onspection By-- Date In .:In By Date <br /> Fee,Is Due: 11 ANNUALLY 0 PER UNIT 11 PER SITE El EACH El January 4 Recoivcd. Jan uagi(I El July I a aece,ved By July 31- <br /> BILLING REMPITANCE <br /> Affivilf <br /> DATE <br /> DAIL �&l TI <br /> BASE - EXPLANATION '-. , ell', <br /> 470 AMOUNT DUE CHECKED <br /> P AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> ............. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 7. <br /> C>k,,* V IV aza <br /> ............................. <br /> Recet. <br /> ved by Date Receipt No Permit No. Issuance Date Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 3801 E.HAZELTON AVE,P.O.Box 2009 $TOCKTON,CA OS201 <br />