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Applications Will Be Processed When Submitted Properly Completed. re ToSignTheApplieafiati.� I t <br /> FGaR oFFdcE USE: ` -APPLICATION SEP 7 pL�J � 1011-1 <br /> (For fmon-Transferable, Revocable,Suspendable) 2 2 1980 <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMftAN OA UIN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYHEALTD1STR)Cr ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County,Ordinance No. 1862 and the rules and regulations�i the Sa_n .foaquin Local ealth District. <br /> Exact Site Address 29 � � City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name - 'f' L/ •• ne <br /> V License# Business Pho <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Rnt <br /> TYPE OF WORK (CHECK):—NEW WELL❑-- DEEPEN ❑ RECONDITION❑ DESTRUCTIO,.N,❑] <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION ; PUMP REPAIR <br /> REPLACEMENT❑ ; <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />'f Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> I <br /> INTENDED USE 13 CABL TOOL <br /> 11 INDUSTRIAL Dia. of Well Excavation <br /> )�Y,06MESTIC/PRIVATE_¢ E-1 DRILLED Dia. of Well Casing . <br /> ❑ OMESTIC/Pl1BLIC ❑ DRIVEN 1 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 /> E Type of Pump i 't. H.P. p[} <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> III 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 /> Homeowner 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 following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I call t r a Gro t ns do prior Title- Date:to grouting and a final inspection. . <br /> Signed <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �y _ <br /> Application Accepted ByDate <br /> Additional Comments: <br /> Phase II Grout Inspection P e III Final Inspection II d <br /> Inspection By Date Inspection By� Dater <br /> -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> { <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> - PRORATION <br /> i PLUS } <br /> PENALTY <br /> F OTHER - <br /> OTHER <br /> -Received by, Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMITtSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />