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Applications Will Re Processed When SubmittedPropertyI„omPleseu c , 8X979 t� <br /> k FOR OFFICE USE: APPLICATION AUGYt <br /> ^�� 11 (For Non-Transferable, Rppgab%e Suspendabie) PUMP&WELL <br /> I Y IZI 7 755 ENVIRONMENTAL HEALTH PERMIAN JOAQUIN LOCAL ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Jo in coal HealthD'+strictforapermittoconstructand/or install the work herein described.This application i <br /> made in compliance with San Joaquin Co my Ordi arjce No. 1862 and the les�nXotions of the San oaquin Local Health District. <br /> City/Town �. Ci- <br /> Exact Site Address z <br /> Phone <br /> 1 Owner's Name F11- Lb <br /> City <br /> Address lu <br /> Contractor's Name <br /> License# G 4/�/ Business Phone Z�q <br /> Emergency Phone 31' _ <br /> Contractor's Address No <br /> R is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ V <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> t REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / � Sewer Lines Pit Privy I <br /> Sewage.disposal Fteld' •'. r •__. rCesspool/Seepage at r�f�r� r _ Other <br /> r Public Domestic Well`I <br /> � property Lihe'�-�-5' Private Domestic Well./>��� - <br /> TYPE OF WELL { <br /> INTENDED USE pia. of Well Excavation if <br /> ❑ INDUSTRIAL 9CABLE TOOL <br /> ❑ DRILLED Dia, of Well Casing <br /> k DO:DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC ; <br /> 1:1 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal r <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHEA3 _ Other Information r <br /> 11 GEOPHYSICAL t, Surface Seal Installed By: <br /> t <br /> f PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> # 11State Work Done <br /> - PUMP RE PLACEMENT: �- f <br /> PUMP REPAIR: ❑ State Work Done i <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: +_ <br /> Describe Material and Procedure <br /> I 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 /> Ir 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 o f.th a work for which this <br /> permit is issued,.l shall employ persons subject to workman's compensation laws of California." <br /> 1 l will II for a Gro t Inspection prior to grouting and a final inspection. j <br /> `. X Title: _ y Date: 1 <br /> Signed <br /> 3 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I a � Date ? <br /> I Application Accepted By ---- <br /> Additional Comments: , A � L� �._..,,�„ <br /> Phase if-Grout Inspection-t I"S Ptia IN Final inspection — <br /> ( Date H ' Z Inspection 13y Dat <br /> Inspection 13y � _,�__-_ - ----V II <br /> .. <br /> I, Fee Is Due: ❑ ANNUALLY El PER UNIT PER SITE © EACH ❑ January,14-Received By January 31 ❑ July 1 &ReceiveRtlEMIITBy uly 31 <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED — <br /> r iEiE ' BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEEj 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY MAY <br /> OTHER <br /> OTHER <br /> �y <br /> Received by - <br /> Date Receipt Na- Permit No. Issuance Date Mailed Delivered <br /> I 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95261 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />