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J <br /> Applications Will Be Processed When Submitted Properly Completed. Be Suo Sign Application. <br /> FOR OFFICE USE: APPLICATION SEP - 1 982 <br /> (For Non-Transferable, Revocable Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT S 41 HEALTHQUIN L <br /> WATER QUALITY D STR T <br /> (COMPLETE IN TRIPLICATE) <br /> �a$_.3fcp _jl , <br /> Application is hereby made to the San Joaquin Local Health Distric;fora permit to construct and/or install the work herein described.This application Is <br /> made in compliance with.San Joaquin C u ty Ordinance o. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Phone <br /> Owner's Name r r, <br /> City Bti; <br /> Address <br /> Contractor's Name License Business Phone } <br /> F h <br /> Contractor's Address r �+ '- -Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ -- <br /> TYPE OF WORK (CHECK): NEW WELL[I DEEPEN ❑• RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER-13. PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit' Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ 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 I . . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor : <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 13 State Work Done r , <br /> PUMP REPAIR: us State Work Done If <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 /> i 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 /> I 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." <br /> Iwil call for a ut Inspection prior to grouting and a final Inspection. <br /> Signed X - <br /> C�-� Title: Date: <br /> ' <br /> (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE IDate <br /> l-c�' <br /> - <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection 2ph se ill Final Inspection <br /> Inspection By �� Date ; Inspection-Bv -Date <br /> r Fee Is D'ue: ❑ ANNUALLY ❑ PER UNIT ❑'PER SITE ❑ EACH' ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedBy July 31 <br /> REMBASE EXPLANATION 'BILLING REMITTANCE $ AMOUNT DUE CHECKED . <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS _ -- <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> I <br /> 11�dl I <br /> Received by D to - 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 />