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' — Applf6�tiblts WIf ��Pgq ss$ySLli�f�len`SQtimitted Properly Completed. Be Sure To Sign The Application: �_ C I `� ti U ? �. .s5f FOR GFOIC&-USE: APPLICATION tle (For Non -Transferable, Revocable, Suspendable) --- — — �— SAN JCAQ�1fN !-00AL PUMP &WELL f HEALTH DIccWyWNMENTAL HEALTH PERMIT EXPLANATION BILLING REMITTANCE $ :)MPLETE IN TRIPLICATE) WATER QUALITY p pplicati on is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstal It he work herein described. This application is +� made in compliance with an Joaq Cou r1ty Qrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District.: UArE I DATE REMITTFD l I Exact Site Addressd� �*�'�� g9 - _ - ---___-------- City.iTown -, ---_' —_r AMOUNT l Owner's Name �/_ Phone Address % _ city Contractor's Name /T14- . I iA 7.41,>, S License # r,-? Business Phone Contractor's Address _/�> Z, E� Emergency Phone _ i Is Certificate of Workman's Compensation. Insurance on File With SJLHD? Yes No TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION ❑ DESTRUCTION❑ ' ' ! WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ^9 REPLACEMENT ❑ DISTANCE TO NEAREST: Septic Tank -_ Sewer Lines Pit Privy PRORATION Sewage Disposal Field cesspooVSeepage Pit Other Property Line - Prlvate Domestic Well __.. ' _ Public Domestic Well INTENDED USE t TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation- ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of. Well Casing ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION t RAVEL PACK Depth of Grout Seal ❑ Gp PENALTY ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information ❑GEOPHYSICAL !f Surface Seal Installed By:. PUMP INSTALLATION: Contractor Type of Pump „' H.P. PUMP REPLACEMENT: ❑ State Work Done MP REPAIR: State Work Done �l ISTRUCTION OF WELL: Well Diameter _ - Approximate Depth Describe Material and Procedure - I I Signed X I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County tic), j ordinances, state laws, and rules and regulations of the Sah-Joaquin Local Health District. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of thework for which•this permit. is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." •- Contractor's hiring or sub-contractingsignature certifies the following: "I certify that in the performance of the work for wh'Ich this permit is issued, I shall employ persons subject to workman's compensation laws of California." I will ca for Gro spection.prior to grouting and a final inspection F.7 _ Title:Dale: — (Draw Plot Plan on Reverse PHASE Application Accepted By Additional Comments:— Inspection By Phase II Grout Inspection Date _ FOR -DEPARTMENT USE ONLY I r Foo 1. n1] f 1 nNN� IA, i v M PFR UNIT ❑ PER SITE -❑ FACH Date — Phase III Final Inspection - Inspection By Date ❑ January 1 & Re rve Ay January 31 ❑ July 1 & Receivec By J.:Iy 31 Received by Date Receipt No. Permi; Nu. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E. HAZELTON AVE., P.O, Bot 20D9 STOCKTON, CA 95201 REMIT BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED UArE I DATE REMITTFD AMOUNT :EES YS ESS ' ' t +� r✓ PRORATION t PLJS PENALTY b OTHER VVr1�l/ - OTNEH Received by Date Receipt No. Permi; Nu. Issuance Date Mailed Delivered APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E. HAZELTON AVE., P.O, Bot 20D9 STOCKTON, CA 95201