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ppications Will Be Procel d hL Submitted Properly Completed. Be Sure To Sign,,The Application. <br /> FOR OFFICE USE: - •` <br /> NOV 25 1981(For fon-TrannssPPb e, RAocabblle,,Suspendable) PUMP&WELL € <br /> ENVIRONMENTAL HEALTH PERMIT I " <br /> SAN <br /> (COMPLETE IN TRI PLICA+if ALTN 1Dt , ;CT WATER QUALITY., <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work':herein described.This application is <br /> made in compliance with San Joaquin C my Ordipapce No.1862 an )the rules and regulations of the Sand JoaquinLocalHealth District. <br /> Exact Site Address • � ell � � City/Town <br /> Owner's Name "[ Phone I' � � <br /> Address fL/ � r �.:�` City g �- <br /> Contractor's Name ! License# Business Phone <br /> Contractor's Address rt Emergency'Phone•- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ice. <br /> TYPE OF WORK (CHECK}v NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ j PUMP REPAIR " <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy " <br /> 0 <br /> Sewage Disposal Field Cesspool/Seepage Pit s Other <br /> Property Line Private Domestic Well Public Domestic'Well :Y <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing li <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �e <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7 <br /> I ❑ DISPOSAL ❑ OTHER Other Information <br /> u <br /> El GEOPHYSICAL ,. Surface Seal Installed By: r00 <br /> PUMP INSTALLATION: contractor r taC L1-G� <br /> Type of Pump, t H1�P. I p <br /> PUMP REPLACEMENT: - .-r' ❑-State Work Done �' G <br /> PUMP REPAIR: State Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Appr ximate Depth <br /> sem. . .rjt Describe Material and Procedure I - <br /> I hereby certify that I have prepared this application and that the work +mill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.a <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I� <br /> I will c 11 to a Grp Inspection prior to grouting-and a final inspectio <br /> Signed Xj" �"� Title: ` +r 1� Date:Y �� <br /> �^ <br /> (Draw Plot Plan on Reverse Side) <br /> ry FOR DEPARTMENT USE ONLY f l f <br /> PHASE I /'eI Date <br /> Application Accepted By '" <br /> Additional Comments: ''' <br /> • F <br /> Pha e 1 Grout Inspection Phase l 11111,Final Inspection <br /> Inspection By Date Inspection By Date 2r"� <br /> jl <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE i' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r IREMIT <br /> .7 <br /> BASE- EXPLANATION BILLING REMITTANCE t $ iill AMOUNT DUE CHECKED <br /> . 3" ;PATE DATE REMITTED AMOUNT <br /> ii <br /> FEE <br /> LESS 4. {i <br /> PRORATION d� <br /> PLUS f <br /> PENALTY <br /> OTHER �I <br /> ' I <br /> OTHER U <br /> -Received by '! Y bate -Receipt No. Permit No.– Issuance Date af-- Mailed Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,'4 I P.O.Box 2004 STOCKTON,CA 85201 <br /> - J <br />