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A`p1i�a1 11141 rof-s Submitted Properly Completed. Be Sure To Sign The Application. / <br /> FOR OFFICE USE: 1111 APPLICATION 40 <br /> (For - ransferable, Revocable,Suspendable) PUMP&WELL <br /> T LL �:Ay 1 1982ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICAi � N JQP=11 <br /> Application is hereby made to �i q o Districtforapermittocon structand/orinstallthe work herein described.This application is <br /> made in compliance with A �No. 1862 and u c ,x4elations of the San Jay4+#1�Lo 1 eat ht District. <br /> Exact Site Address !v IV� ��31� City/Town <br /> Owner's Nam ��� , �� ,�u e <::z, Phone <br /> Inj <br /> Address City T <br /> Contractor's Name" License# Business h ne 7 <br /> Contractors Address J-1Pr T 'Emergency Phone 4� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes =� No r-- <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT© OTHER ❑ PUMP INSTALLATION®-� PUMP REPAIR 13 <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE i ❑ 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 Surface779- I Installed By: C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 f <br /> PUMP REPLACEMENT: IState Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: „l 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:1 certify that in the performance of the work for which this permit <br /> is issued, l shall n ploy any person in such manner as to become sub to workman's compensation laws of California." <br /> Contractor's h' g or sub-contracting signature certifies the following:" ce y that in the performance of the work for which this <br /> pe I iss d, I sha I emplo rso subject to workman's compe s Ion laws of California." , <br /> will r Inspectl prior o grouts an a final inspe n., - � <br /> Signed X <br /> Title: Date- - <br /> F (Draw Plot Plan n Reverse Side) z <br /> FOR ARTMENT USE ONLY <br /> PHASE 1 <br /> Application Acce4te y Date <br /> Additional Comm : <br /> Phase II Grout Inspection P a III Final Inspection <br /> Inspection By Date Inspection By j� Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEET 5 <br /> LESS t <br /> PRORATION I - <br /> PLUS <br /> PENALTY 1 <br /> OTHER ' <br /> :j <br /> OTHER <br /> Received by Date -Receipt No. Permit No. - 14dance qale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.D.Bo■2009 STOCKTON,CA 95201 <br />